HIT 205 - International Classification of Diseases Diagnosis Coding II With Lab

Spirochetal

a gram-negative bacteria made up of spiral-shaped cells

ligaments

bands of connective tissue that connect the joints.

first-degree burn

burns that do not present a danger to the patient because they are limited to the outer layer of the epidermis.

In the Index the primary arrangement for diagnoses is by ________. a. site b. severity c. condition d. location

c. condition

Carcinoma

cancer of epithelial cells of connective tissue.

Sarcoma

cancer of supportive tissue, such as blood vessels, bones, cartilage, and muscles.

Leukemia

cancer of the blood-forming organs.

Lymphoma

cancer of the lymph nodes and immune system.

Malignant neoplasms

cancerous growth.

Somatoform disorders

characterized by symptoms that suggest a physical illness or disease but for which there are no organic causes or physiologic dysfunctions.

bile

chemical secreted by the liver to help in digestion.

Sideropenic dysphagia

a type of iron-deficiency anemia that becomes so severe that the patient has difficulty swallowing in addition to the other symptoms of anemia; also known as Plummer-Vinson syndrome

degenerative joint disease

a type of osteoarthritis.

assault

a violent crime committed against another.

cuncussion

a violent shaking or jarring of the brain.

Folate

a water-soluble B vitamin most commonly found in food.

appendix

a wormlike structure that is found at the blind end of the cecum.

Colles fracture

a wrist fracture that typically occurs when a person tries to break a fall by extending the arm.

Which of the following is NOT a member of the Cooperating Parties for ICD-10-CM? a. AMA b. AHIMA c. AHA d. CMS

a. AMA (American Medical Association)

joints

allow for bending and rotating movements.

Middle ear

also known as the tympanic cavity; found in the temporal bone and houses the auditory ossicles.

dermatitis

an inflammation of the upper layer of the skin.

spondylitis

an inflammation of the vertebrae.

Viral hepatitis meaning

an inflammatory condition of the liver caused by a virus.

polycystic kidney disease

an inherited disorder in which the kidneys gradually lose the ability to function due to the grapelike clusters of cysts that form.

strain

an injury at the joint site to a muscle or tendon.

sprain

an injury to a joint, specifically the ligament of the joint that becomes stretched.

burn

an injury to body tissue as a result of heat, flame, sun, and/or chemicals, radiation, or electricity.

complicated fracture

an internal organ injured as a direct result of the fracture.

animate object

an object capable of moving on its own.

poisoning

an overdose of a substance or the intake of a wrong substance given or taken in error.

peptic ulcer

an ulcer that occurs in an unspecified site of the GI tract.

Gastrojejunal ulcer

an ulcer that occurs in the stomach and the jejunum.

gastric ulcer

an ulcer that occurs in the stomach.

duodenal ulcer

an ulcer that occurs in the upper part of the small intestine.

Pancreas

anatomically located under the stomach in the upper abdomen; performs various physiological functions.

pancreas

anatomically located under the stomach in the upper abdomen; performs various physiological functions.

Vitamin B12 deficiency anemia

anemia due to an insufficient dietary intake of vitamin B12 or the inability of the body to absorb vitamin B12 appropriately.

Category B34 reports viral infections of unspecified site. The Excludes1 note identifies the following:

anogenital human papillomavirus infection (A63.0) cytomegaloviral disease NOS (B25.9) herpesvirus [herpes simplex] infection NOS (B00.9) retrovirus infection NOS (B33.3) viral agents as the cause of diseases classified elsewhere (B97.-) viral warts due to human papillomavirus infection (B07)

alimentary canal

another name for the digestive system.

Incus

anvil-shaped bone of the middle ear; one of the auditory ossicles.

myelopathy

any disorder of the spinal cord.

pedestrain

any person who is not riding in or on any type of motor or wheeled form of transportation.

Instructional notes

appear in both the Tabular List and Alphabetic Index of ICD-10-CM and provide further instruction for the coder.

In Diseases Classified Elsewhere

applies to the etiology/manifestation conventions.

greenstick fracture

as with a greenstick of a tree, the bone bends as well as breaks.

What is (EVALI)

associated lung injury caused by E-cigarettes or vaping

Blepharochalasis

atrophy of the intercellular tissue that causes relaxation of the skin of the eyelid.

lateral

away from the midline toward the side.

The EXCLUDES 2 note represents all of the following except ________. a. that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time b. that it is a pure excludes note c. the note represents "not included here" d. when the note appears under a code, it is acceptable to use both the code and the excluded code together when applicable

b. that it is a pure excludes note

posterior

back or behind

Septicemia

bacteremia with sepsis.

Certain Zoonotic Bacterial Diseases (Category Codes A20-A28):

bacterial diseases that are transmitted to humans after contact with infected animals, insects, fleas, ticks, or their discharges or products.

adipose tissue definition

commonly known as body fat

What is CC?

complication or comorbidity diagnosis which affects DRG assignment.

tendons

connect muscle to bone.

screening examinations

examinations used to screen, or look, for diseases.

hirsutism

excessive hair growth.

stress fracture

excessive impact on the bone causes small hairline crack.

Blepharitis

inflammation of the eyelid

Transcobalamin II

necessary to transport vitamin B12.

Neoplasms of uncertain behavior

neoplasms in which cells are not histologically confirmed even after pathological investigation

heart attack

occurs when there is inadequate blood supply to a section or sections of the heart; also known as myocardial infarction.

Dual-code assignment

occurs when two codes are needed to code a diagnostic statement

Inhalants

substances that are inhaled for their euphoric effect.

Optic disc

the blind spot on the optic nerve that is the point of entry for the artery supplying blood to the retina.

comminuted fracture

the bone is crushed and may be splintered.

pulp

the center of a tooth.

Pupil

the center of the iris that controls the amount of light entering the eye.

Vestibule

the central portion of the inner ear.

What is "coding"?

the language used by insurance companies and healthcare providers to describe what brought a person (why?) to a facility for treatment and what services were performed (what?)

epidermis

the outermost layer of the skin.

morbidity

the rate or frequency of disease; diseased state.

micturate

voiding or urinating.

At the start of the A15-A19 coding section of ICD-10-CM, an Includes note states that infections due to Mycobacterium tuberculosis and Mycobacterium bovis are coded from this section. An Excludes1 note excludes from this code block:

- Congenital tuberculosis (P37.0) - Nonspecific reaction to test for tuberculosis without active tuberculosis (R76.1-) - Pneumoconiosis associated with tuberculosis, any type in A15 (J65) - Positive PPD (R76.11) - Positive tuberculin skin test without active tuberculosis (R76.11) - Sequelae of tuberculosis (B90.-) - Silicotuberculosis (J65)

Common Addictive Drugs Inhalants

Anesthetic gases Diprivan; Propofol Gasoline/paint thinner Poppers, snappers; nitrous oxide Propellant

Malignant Versus Benign Neoplasms: Patients with malignant conditions may experience:

Anorexia Abnormal bleeding or bruising Difficulty swallowing Indigestion Malaise Fever Sores that do not heal or that change to the appearance of a wart or mole Bladder and bowel habit changes Mass growth in the breast or other body site Persistent cough Weight loss

Pernicious anemia Signs and Symptoms:

Anorexia Gastrointestinal symptoms that include diarrhea or intermittent constipation Nonlocalized abdominal pain Atrophic gastritis Fatigue Shortness of breath Pallor Positive Babinski's reflex

Certain Zoonotic Bacterial Diseases (Category Codes A20-A28): Diseases include:

Anthrax Bubonic plague Glanders and melioidosis Leptospirosis

Viral hepatitis Treatment:

Antiviral drug therapy Bed rest A gradual return to normal activity without overexertion

True or False Code N18.7, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).

False. Code is N18.6

An understanding of the symptoms of tuberculosis is important. Symptoms of the disease are:

Fatigue and weakness Loss of appetite and weight Coughing Hemoptysis Night sweats Increased temperature late in the day and evening Pulmonary hemorrhage Dyspnea

Acute Myocardial Infarction (AMI) time coding:

For encounters: - up to 4 weeks = I21 - more than 4 weeks but still being treated = use aftercare code - Old or healed = I25.2

Coding of Diseases of the Nervous System

G00-G09, Inflammatory diseases of the central nervous system G10-G14, Systemic atrophies primarily affecting the central nervous system G20-G26, Extrapyramidal and movement disorders G30-G32, Other degenerative diseases of the nervous system G35-G37, Demyelinating diseases of the central nervous system G40-G47, Episodic and paroxysmal disorders G50-G59, Nerve, nerve root, and plexus disorders G60-G65, Polyneuropathies and other disorders of the peripheral nervous system G70-G73, Diseases of myoneural junction and muscle G80-G83, Cerebral palsy and other paralytic syndromes G89-G99, Other disorders of the nervous system

Diseases of the Middle Ear and Mastoid (Category Codes H65-H75)

H65, Nonsuppurative otitis media H66, Suppurative and unspecified otitis media H67, Otitis media in diseases classified elsewhere H68, Eustachian salpingitis, and obstruction H69, Other and unspecified disorders of Eustachian tube H70, Mastoiditis and related conditions H71, Cholesteatoma of the middle ear H72, Perforation of tympanic membrane H73, Other disorders of the tympanic membrane H74, Other disorders of middle ear mastoid H75, Other disorders of middle ear and mastoid in diseases classified elsewhere

The rule of nines breaks down as follows:

Head and neck, 9% Arms, 9% each Legs, 18% each Anterior trunk, 18% Posterior trunk, 18% Genitalia, 1%

Profound intellectual disabilities

IQ below 20-25; also referred to as profound mental subnormality or profound mental retardation.

Severe intellectual disabilities

IQ of 20-25 to 35-40; also referred to as severe mental subnormality or severe mental retardation.

Codes specifying plegia or paresis should indicate if a dominant or non-dominate side of the patent is affected. If the side is documented with no default classification:

If plegia is affecting: - Ambidextrous patient: default is dominant - Left side affected: default is non-dominant - Right side affected: default is dominant

Diseases of the skin and subcutaneous tissue, category code range:

L00-L99 ICD-10-CM Chapter 12

These Standards of Ethical Coding have been revised in order to reflect the current healthcare environment and ____________ coding practices.

Modern

Severe sepsis, ONLY when acute organ dysfunction is documented OR organ dysfunction is documented as associated with sepsis is coded as:

R65.2

The extent of the body surface burned is coded according to the rule of nines What is the rule of nines?

based on the premise that the adult body can be divided into anatomic regions with surface area percentages that are multiples of nine.

G10-G14, Systemic atrophies primarily affecting the central nervous system

This block of codes includes some congenital disorders such as code G11.0, Congenital nonprogressive ataxia. Coders must carefully read the diagnostic statement and match it with one of the many diagnostic descriptions in this block. For example, code G12.1, other inherited spinal muscular atrophy, has many diagnostic descriptions following the heading.

When to code a Pedestrian Injured in Transport Accident

To be coded as a transport accident, the vehicle involved must be used for transport purposes, and must be moving or running at the time of the accident. Coders need to see the Includes and Excludes notes before codes are assigned. Numerous instructional notations appear at the category level that identify the appropriate seventh characters.

What are (ENDS)?

battery powered vaping devices such as vapes, electronic pipes, electronic cigarettes, and other electronic nicotine delivery systems

Acariasis

being run over or infested with mites or acariads

kidneys

bilateral organs located against the dorsal wall that filter blood constantly to remove waste. The primary organ of the urinary system

cerebral hemorrhage

bleeding in the brain or layers of brain lining.

Otorrhagia

bleeding, or hemorrhage, from the ear

Occlusion of cerebral and precerebral arteries

blocking of the arteries

Labyrinth

bony and membranous structures of the inner ear.

Semicircular canals

bony structures filled with fluid that help maintain balance.

fracture (Fx)

broken bones resulting from undue force or pathological changes.

Molds

caused by long filament-shaped fungi.

Benign tumors

caused by noncancerous growth of cells.

Yeast infection

caused by unicellular fungi that reproduce by budding.

Agranulocytes

cells that do not have a granular appearance.

Melanocytes

cells that produce dark pigment.

Granulocytes

cells with a granular appearance.

Factitious disorder

characterized by a patient exhibiting disease symptoms caused by the patient's deliberate actions to gain attention.

Impulse disorders

characterized by a sudden desire or urge to act without consideration of consequences that may result.

Dissociative disorders

characterized by emotional conflicts in which the patient represses the emotions in such a manner that a separation in the personality occurs.

Hormones

chemical substances produced by the body to keep organs and tissues functioning properly.

Intestinal Infectious Diseases (Category Codes A00-A09) include:

cholera, shigellosis, and other bacterial intestinal infections. Also found here are codes for food poisoning, cyclosporiasis, and viral intestinal infections.

Diabetes mellitus

chronic problem resulting from problems with the pancreas.

Intellectual disabilities

classified as mild, moderate, severe, or profound based on the person's current level of functioning.

What is the Gustilo classification of Fractures?

classifies open fractures into three major categories based on the mechanism of injury, degree of soft tissue damage, and degree of skeletal involvement or bone injury.

medial

closest or nearest to the midline of a structure.

NOS (not otherwise specified)

codes are not specific and should be used only after the coder has clarified with the physician that a more specific code is not available.

Conjunctiva

colorless mucous membrane that lines the anterior part of the eye.

Hordeolum

commonly known as a sty. A sty; an acute infection of a sebaceous gland of the eyelid

occlusion

complete closure of an orifice or lumen of a tubular body part, such as a vessel.

ankylosis

complete fusion of the vertebrae.

Alpha thalassemia

condition in which there is a deficiency in the alpha protein being produced.

Beta thalassemia

condition in which there is a lack of beta protein being produced.

Cancer

condition that is characterized by malignant neoplasm.

Cushing's syndrome

condition that results from the excessive and chronic production of cortisol by the adrenal cortex or by the administration of glucocorticoids in large doses for a period of several weeks or longer.

Conversion disorders

conditions occurring when a patient represses emotional conflicts; sensory, motor, or visceral symptoms occur.

Secondary diagnoses

conditions that are not responsible for admission but that exist at the time of treatment.

acquired conditions

conditions that occur during a person's life.

cleft lip

congenital defect that results in a deep groove or opening of the lip running upward to the nose; also called a harelip.

Volkmann's deformity

congenital dislocation of the tibiotarsal

varus deformities of feet

congenital inward turning of the feet.

Constitutional aplastic anemia

congenital or hereditary anemia

valgus deformities of feet

congenital outward turning of the feet.

Other Bacterial Diseases (Category Codes A30-A49) Includes such conditions as:

congenital syphilitic pneumonia gonococcal infections other sexually transmitted diseases *Careful attention to the documentation is necessary to properly assign a code from this section because the selection of codes from this range of codes is very specific.

fascia

connective tissue that not only covers but supports and separates muscle.

Auditory tube

connects the bony structures of the middle ear to the pharynx; also known as eustachian tube.

Eustachian tube

connects the bony structures of the middle ear to the pharynx; also known as the auditory tube.

Pharyngotympanic tube

connects the bony structures of the middle ear to the pharynx; also known as the eustachian tube.

liver

considered an accessory organ of the digestive system that filters red blood cells, produces glycogen, and secretes bile.

Bony labyrinth

consists of bones that make up the inner ear.

Endocrine system

consists of several different internal groups of glands and structures that produce or secrete hormones. (endo- means "within," and -crin means "secrete")

True or False: Bacteria can live inside or outside the body.

True. Outside the body, bacteria can be found on most surfaces, such as countertops, faucet handles, and doorknobs. Inside the body, some common bacterial infection sites are the bloodstream, the skin, and the gastrointestinal, respiratory, and urinary tracts.

Gustilo Classification of Fractures, types:

Type I Wound is less than 1 centimeter. Soft tissue injury is minimal. Wound bed is clean. Commonly a low-energy type of injury. Fractures are typically a simple transverse fracture, short oblique fracture, or minimally comminuted. Type II Wound is greater than 1 centimeter. Soft tissue injury is moderate. Wound bed has no contamination or is minimally contaminated. Commonly a low-energy type of injury. Fractures are typically a simple transverse fracture, short oblique fracture, or minimally comminuted. Type III Wound is greater than 1 centimeter. Extensive damage to soft tissue, including muscle, skin, and neurovascular structures. Commonly a high-energy type of injury with a severe crushing component. Types of injury patterns that are classified as type III include: Open segmental fracture, regardless of size of the wound Gunshot wounds Open fracture with neurovascular injury Farm injuries with contamination from soil Traumatic amputations Open fractures with treatment delay of over 8 hours Mass casualties, such as from war or tornados

Rickettsioses (Category Codes A75-A79 Bacterial infections include:

Typhus fever Spotted fever Q fever Trench Fever Other specified and unspecified rickettsioses

Code reporting Vaping-related disorder:

U07.0

What code reports Covid-19?

U07.1

What is the code for COVID-19?

U07.1

Acute Myocardial Infarction (AMI), unspecified codes:

Unspecified AMI or unspecified type: I21.9 Type 1 STEMI or transmural MI w/out site documented: I21.3

Code U07.0 also contains the following instructional notation:

Use additional code to identify manifestations, such as: - abdominal pain (R10.84) - acute respiratory distress syndrome (J80) - diarrhea (R19.7) - drug-induced interstitial lung disorder (J70.4) - lipoid pneumonia (J69.1) - weight loss (R63.4)

opportunistic parasites are:

Yeasts and molds that infect human tissues.; they cause opportunistic infections when a patient has a weakened immune system.

Code used when patient is listed as HIV positive or has known HIV but has no symptoms:

Z21

If a patient comes in for an issue and just happens to be pregnant, code pregnancy as incidental using the supplemental code:

Z33.1

Use additional code from category _____, weeks of gestation, to identify the specific week of the pregnancy if known.

Z34

prenatal visit codes:

Z34 = routine/normal visit O09 = high-risk pregnancy visit O80 = No complications of delivery/high risk pregnancy

Delivery outcome code

Z37

Additional code from category ______, weeks gestation, to identify the specific week of the pregnancy, if known

Z3A

For administration of therapy only what code is listed first?

Z51 (first listed diagnosis), neoplasm secondary

For administration of therapy then develops complications, code as:

Z51, listed diagnosis, first; complication, secondary; neoplasm, third

Counseling code in regards to HIV testing

Z71.7

Code ______ should not be assigned if insulin is given temporarily to bring a secondary diabetic patient's blood sugar under control during an encounter.

Z79.4

Rickettsioses

a bacterial infection that is caused by a Richettsia organism.

Pterygium

a benign growth over the conjunctiva of the eye.

Lipoma

a benign neoplasm of adipose tissue.

molar pregnancy

a blighted ovum in the uterus that develops into a mole or benign tumor.

Portal vein thrombosis

a blood clot in the main vein of the liver.

luxation

a body part has moved out of place; also known as dislocation.

dislocation

a body part has moved out of place; also known as luxation.

pathologic fracture

a break of diseased bone that occurs from a minor stress or injury that would not normally occur in healthy bone.

corrosions

a burn due to chemicals.

Posterior chamber

a chamber located behind the lens of the eye.

Anterior chamber

a chamber located in front of the lens of the eye.

COPD (Chronic obstructive pulmonary disease)

a chronic inflammatory lung disease that causes obstructed airflow from the lungs

Vitreous humor

a clear, jellylike fluid that fills the posterior chamber of the eye and that helps to shape the eye.

Lens

a colorless structure that allows the eye to focus on images.

Cancerous growths

a condition in which cancer cells multiply; also called a malignant neoplasm

pneumonia

a condition in which liquid, known as exudates, and pus infiltrate the lung and cause inflammation.

Hemiplegia

a condition in which one side of the body is paralyzed due to brain hemorrhage, cerebral thrombosis, embolism, or a tumor of the cerebrum; a synonym for hemiparesis.

Hemiparesis

a condition in which one side of the body is paralyzed due to brain hemorrhage, cerebral thrombosis, embolism, or a tumor of the cerebrum; a synonym for hemiplegia.

Pure red cell aplasia

a condition in which precursors to the red blood cells are affected in the bone marrow and eventually cease to be produced.

Acquired immunodeficiency syndrome (AIDS)

a condition in which the body's immune system deteriorates.

Idiopathic aplastic anemia

a condition in which the bone marrow is not able, for unknown reasons, to produce cells properly

Eosinophilia

a condition in which the eosinophil white blood cell is found in excess in the blood or body tissues.

Thrombophilia

a condition in which the patient is predisposed to develop thromboses.

Goiter

a condition in which the thyroid becomes enlarged even though hormone secretions fall within normal limits.

syncope

a condition in which there is a brief loss of consciousness due to lack of oxygen to the brain; also known as fainting.

Anemia

a condition marked by a decrease in red blood cells, hemoglobin, hematocrit, or a combination thereof. Cancer patients can experience anemia, a deficiency of the red blood cells, caused by the malignancy or chemotherapy.

spina bifida

a congenital condition in which the spinal canal fails to close around the spinal cord.

harelip

a congenital defect that results in a deep groove or opening of the lip running upward to the nose; also called a cleft lip.

cleft palate

a congenital groove or opening of the palate that involves the hard palate, soft palate, or both, as well as the upper lip.

What is Covid-19

a contagious viral r3espiratory infection

Pancytopenia

a decrease in the number of platelets, white blood cells, and red blood cells.

heart failure

a decreased ability of the heart to pump a sufficient amount of blood to the body's tissue.

coma

a deep state of unconsciousness.

Angiohemophilia

a deficiency in the clotting factor and platelet function; also known as Von Willebrand disease

Multiple sclerosis (M.S.)

a demyelinating disorder in which patches of hardened tissue form in the brain or spinal cord and cause partial or complete paralysis and muscle tremors.

anomaly

a deviation from what is normal in the development of a structure or organ.

birth defect

a deviation from what is normal in the development of a structure or organ; also called an anomaly.

Otorrhea

a discharge from the external ear.

Parasitic diseases

a disease caused by an organism that lives within another organism and that can cause illness.

Alzheimer's disease

a disease in which brain structure changes lead to memory loss, personality changes, and ultimately impaired ability to function.

Lupus

a disease in which the body produces too many antibodies, which begin to turn against the patient's own body, attacking body organs, joints, and muscles.

nephropathy

a disease or disorder of the kidney.

nephrosis

a disease or disorder of the kidney.

Eponyms

a disease/condition named for the person who discovered it or a famous person with the condition

Cerebral palsy

a disorder in which the motor function of the brain is impaired; present at birth, chronic, and nonprogressive.

Methemoglobinemia

a disorder of the hemoglobin in which oxygen is not able to be transported by the cells.

congenital anomaly

a disorder that exists at the time of birth and may be a result of genetic factors, agents causing defects in the embryo, or both.

Insulin-dependent diabetes mellitus (IDDM)

a form of diabetes in which the patient requires insulin injections to survive; patient may be a type I or a type II diabetic.

Hereditary factor VIII (8)

a form of hemophilia

Cochlear duct

a membranous structure that aids in the hearing process.

Pathogen

a microorganism that can cause disease in humans.

heart

a muscular organ that pumps blood throughout the body.

urethral stricture

a narrowing of the urethra.

second-degree burn

a partial-thickness burn that forms blisters.

Alcoholism

a person becomes dependent on alcohol and is unable to stop drinking even though the alcoholism has negative effects on the person's health, social relationships, and normal daily activities such as work; also known as alcohol dependence.

Alcohol dependence

a person becomes dependent on alcohol and is unable to stop drinking even though the alcoholism has negative effects on the person's health, social relationships, and normal daily activities such as work; also known as alcoholism.

Pica

a person has an abnormal craving and eating of substances that are not normally eaten by humans.

Nicotine

a poisonous alkaloid found in tobacco.

ectopic pregnancy

a pregnancy that occurs outside the uterus.

deformity

a problem in the structure or form that may or may not be disfiguring.

Parkinson's disease

a progressive disease characterized by a masklike facial expression, weakened muscles, tremors, and involuntary movement.

direct inguinal hernia

a protrusion in the groin area.

hernia

a protrusion or bulge through the tissue that normally contains the structure.

Indirect inguinal hernia

a protrusion that has moved to the scrotum.

Obsessive-compulsive disorder (OCD)

a psychoneurotic disorder where the patient has obsessions or compulsions and suffers extreme anxiety or depression that can interfere with the patient's ability to function occupationally, interpersonally, or socially.

Schizophrenia

a psychotic disorder characterized by disruptive behavior, hallucinations, delusions, and disorganized speech.

Tic disorder

a repetitive involuntary muscle spasm that is usually psychogenic and that can increase due to stress or anxiety.

avulsion

a ripping or tearing away.

Petit mal

a seizure, less severe than a grand mal.

Severe sepsis

a septic infection with associated acute organ dysfunction or failure.

spiral fracture

a severe twisting motion causes the bone to twist apart.

Point dash

a signal to the coder that the code contains a list of options at a level of specificity past the three-character category.

Combination-code assignment

a single code used to classify two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication

Combination code

a single code used to classify two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication.

urethra

a small tube extending from the bladder to outside the body.

Chalazion

a small tumor of the eyelid caused by the retention of secretions of the Meibomian gland.

bedsores

a sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as decubitus ulcer, pressure ulcer, or pressure sore.

Pharyngitis

a sore throat

calculus

a stone in the kidney or ureter.

Adnexa

a term for the accessory or appendage of an organ.

Membranous labyrinth

a term used to describe the structures in the inner ear that are not bony structures.

Culture and sensitivity (C&S)

a test that identifies the type of organism causing the infection (the culture), and the sensitivity identifies the antibiotic that should be used to treat the infection.

Epilepsy

a transient disturbance of cerebral function that is recurrent and characterized by episodes of seizures.

Cornea

a transparent nonvascular structure located on the anterior portion of the sclera.

Chlamydiae

a type of bacteria that lives inside a host cell and is usually dormant but at some point can become active in a disease process.

Noninsulin-dependent diabetes mellitus (NIDDM)

a type of diabetes in which the patient does not require insulin injections to survive; the diabetic patient might be controlled by diet, exercise, or other medications outside of insulin, and is usually a type II diabetic.

cellulitis

a type of infection that develops in the layers of the skin.

regional enteritis

a form of inflammatory bowel disease that can cause the thickening and scarring of the abdominal wall; also known as Crohn's disease.

Chron's disease

a form of inflammatory bowel disease that can cause the thickening and scarring of the abdominal wall; also known as regional enteritis.

hair

a form of protection used by the body to keep foreign material from entering through the skin.

complete or simple fracture

a fracture in which the bone is broken but the skin has not been broken; also known as a closed or simple fracture.

closed fracture

a fracture in which the bone is broken but the skin has not been broken; also known as a complete or simple fracture.

open fracture

a fracture that has broken through the skin at the fracture site; also known as a compound fracture.

compound fracture

a fracture that has broken through the skin at the fracture site; also known as an open fracture.

Moniliasis

a fungal infection that can affect various sites; also called candidiasis.

Conventions

a group of instructional notes, punctuation marks, abbreviations, and symbols.

Otosclerosis

a growth of spongy bone in the inner ear.

Agammaglobulinemia

a hereditary disorder in which the immunoglobulin (immune proteins) are extremely low, leaving the person open to infection.

Sepsis

a life-threatening bacterial infection that causes clots to form, which block blood flow to vital organs.

abscess

a localized collection of pus; indicates tissue destruction.

Dementia

a loss of brain function that impacts memory, language, judgment, and the ability to think logically.

Epiphora

tearing of the eyes.

terrorism

the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof in the furtherance of political or social objectives.

incomplete prolapse

the uterus descends into the introitus.

Compression fractures of the spine

the vertebrae in the spine become weak and collapse under low stress.

Human immunodeficiency virus (HIV)

the virus that leads to AIDS

External ear

the visible part of the ear, not within the structure of the skull.

Sclera

the white portion of the eye that maintains the shape of the eyeball.

trachea

the windpipe

pharnyx

throat

Cilia

tiny hairs along the external auditory canal.

Gastrointestinal (GI) tract

tract of the digestive system.

Altered state or consciousness

transient alteration of awareness; altered loss of awareness.

Neoplasms of unspecified behavior

tumors in which the morphology and behavior of the neoplasm are not specified in the patient's medical record

Trichiasis

turning in of the eyelashes

Type 2 diabetes mellitus

type of diabetes in which the body is unable to produce sufficient amounts of insulin in the pancreas; patient might be insulin dependent or not; also known as adult-onset diabetes.

Type 1 diabetes mellitus

type of diabetes with insufficient amount of insulin secretion, so that the patient requires insulin injections; also known as juvenile diabetes.

pedal cycle

type of transportation operated by a person without the help of a motor.

Diagnoses documented as probable, suspected, or questionable are ________. a. reported by physician choice b. reported in outpatient settings c. reported in all settings d. reported in the inpatient setting

d. reported in the inpatient setting

bones

dense, porous, calcified connective tissue that protect the internal organs and form the framework of the body.

Neoplasms are:

described according to the form and structure of the neoplastic growth of the cell, known as the morphology, and the anatomical site.

varicose veins

dilated superficial veins of the legs.

Red blood cells (RBC)

disc-shaped cells formed in the bone marrow that contain hemoglobin.

Glaucoma

disease of the eye marked by increased pressure in the eyeball that may result in damage to the optic nerve, causing the gradual loss of vision.

cardiomyopothy

disease of the heart muscle

Infectious diseases

diseases that occur when a microorganism invades the body and causes disease.

Dorsopathies

disorders of the back.

Infectious arthropathies

disorders of the joints that are caused by an infectious agent.

Cerebrovascular accident (CVA)

disruption in the normal blood supply to the brain; also called a stroke.

Female genital prolapse

downward displacement of the genital organs.

Alcohol abuse

drinking alcohol to excess but not having a physical dependence on it.

Sedatives

drugs that induce a relaxed state and calm or tranquilize a patient.

Secondary diabetes definition:

due to or stemming from. Diabetes is due to something. Also, code Z79 to indicate any long-term medication used to control diabetes.

Otalgia

earache

Tympanic membrane

eardrum

Transient hypertension

elevated/high blood pressure

complete prolapse

entire uterus descends and protrudes beyond the introitus, and the vagina becomes inverted.

ulcers

erosions of the skin in which tissue becomes inflamed and then lost.

For category heading 122, acute myocardial infarction, use additional code to identify the following:

exposure to environmental tobacco smoke (Z77.22) history of tobacco dependence (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (Z92.82) tobacco dependence (F17.-) tobacco use (Z72.0)

For category heading 120, Angina pectoris, use additional code to identify the following:

exposure to environmental tobacco smoke (Z77.22) history of tobacco dependence (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0)

Aplastic anemia

failure of blood cell production in the bone marrow

Melanoma

fast-growing cancer of melanin-producing cells.

melanoma

fast-growing cancer of melanin-producing cells.

7th character determines what?

fetus number, in cases where there are multiple babies in the pregnancy

Certain Zoonotic Bacterial Diseases (Category Codes A20-A28): Common symptoms of diseases in this range include:

fever chills headache sweating body aches weakness fatigue

Candidiasis

fungal infections caused by the Candida fungus; also known as moniliasis.

carbuncles

furuncles cluster and form a puslike sac.

Sickle-cell anemia

genetic disorder in which the development of an abnormal type of hemoglobin in red blood cells causes decreased oxygenation in the tissues.

sebaceous

glands of the skin that produce an oily secretion to condition the skin.

alopecia

hair loss

Malleus

hammer-shaped bone found in the middle ear; one of the auditory ossicles.

nails

hardened cells of the epidermis.

secondary hypertension

high arterial blood pressure due to another disease, such as vascular disease.

Influenza

highly contagious respiratory disease. Commonly known as the flu.

muscles

holds the body erect and allows movement.

urinary bladder

holds urine until it moves to the urethra.

Cerumen

honey-colored, thick, waxy substance; also known as earwax.

adverse affect

hypersensitivity or reaction to a correct substance properly administered.

Code Z79:

hypoglycemic (primary or secondary diabetes) - Addtn'l code for continued used. - No code assigned for temp use to control blood sugar.

Healed myocardial infarction

identifies a history of a heart attack in the past

Old myocardial infarction

identifies a history of a heart attack in the past

in situ meaning

in the normal location

Lagophthalmos

inability to close the eyelids completely

Delusional disorders

include the feeling of paranoia in which the patient has a constant distrust and suspicion of others.

Nocturnal enuresis

incontinence of urine that occurs at night; also known as bed wetting.

Bed wetting

incontinence of urine that occurs at night; also known as nocturnal enuresis.

Enuresis

incontinence of urine.

Polysubstance drug use

indiscriminate use of multiple drugs.

Pediculosis

infestation with lice

arthritis

inflammation of a joint.

appendicitis

inflammation of the appendix

Encephalitis

inflammation of the brain

Encephalomyelitis

inflammation of the brain and spinal cord

bronchitis

inflammation of the bronchus

acute bronchitis

inflammation of the bronchus that lasts for a short period of time.

colitis

inflammation of the colon

diverticulitis

inflammation of the diverticula

Cholecystitis

inflammation of the gallbladder

glomerulonephritis

inflammation of the glomeruli of the kidneys.

myocarditis

inflammation of the heart muscle.

enteritis

inflammation of the intestines

Dacryoadenitis

inflammation of the lacrimal gland

peritonitis

inflammation of the lining of the abdominal cavity.

Lymphadenitis

inflammation of the lymph nodes

Myelitis

inflammation of the spinal cord

Thyroiditis

inflammation of the thyroid gland

urethritis

inflammation of the urethra

Parasite

lives within another organism and may or may not cause disease.

Eyelashes

located along the edge of the eyelids to protect the eye from foreign material.

Sp

located in the upper-left quadrant of the abdomen; the site of lymphocyte and monocyte formation and erythrocyte storage.

hypotension

low blood pressure.

larnyx

made up of cartilage and ligaments that compose the vocal cords or voice box.

male genitalia

made up of the scrotum, testicles, and the penis.

vault of the skull

made up of the two parietal bones and the frontal bone.

obstetrical care

medical care that occurs during pregnancy and childbirth.

Saccule

membranous sac that aids in maintaining balance.

Fungi

microscopic plant life that lack chlorophyll and are not able to manufacture their own food.

Osteoarthritis (OA)

most common form of arthritis; causes the degeneration of the articular cartilage.

Purpura

multiple pinpoint hemorrhages and accumulation of blood under the skin

Ciliary body

muscles responsible for adjusting the lens.

stenosis

narrowing of the cerebral arteries that supply blood to the brain.

Glucose

needed for the cells to properly supply energy for the body's metabolic functions. The molecular formula C6H12O6

Ca in situ (CIS)

neoplastic cells that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also called transitional cell carcinoma, noninfiltrating carcinoma, noninvasive carcinoma, and preinvasive carcinoma

Carcinoma in situ (CIS)

neoplastic cells that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also called transitional cell carcinoma, noninfiltrating carcinoma, noninvasive carcinoma, and preinvasive carcinoma.

In situ neoplasms

neoplastic cells that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also known as carcinoma in situ; ca in situ, or CIS

Myocardial infarction (MI)

occurs when there is inadequate blood supply to a section or sections of the heart; also called a heart attack.

Assignment of MS-DRG:

often depends on the presence or absence of a secondary diagnosis code that is designated. s MCC or CC

geographic tongue

on the tongue, irregularly shaped patches that resemble landforms on a map.

impacted fracture

one end of the broken bone is wedged into the other bone.

Endolymph

one of the auditory fluids found in the cochlea that aid in hearing.

Thrombocytes

one of the cellular elements of blood; also known as platelets.

Perilymph

one of two auditory fluids found in the inner ear that aid in the transmission of sound.

Bacteria

one-celled organisms named according to their shapes and arrangements.

Protozoa

one-celled organisms that live on living matter and are classified by the way they move.

Unspecified Mental Disorder (Category Code F99)

or mental disorders that are not specified elsewhere or that are listed in the patient's record as mental illness not otherwise specified.

Helminths

organisms that include flatworms, roundworms, and flukes.

Arthropods

organisms that include insects, ticks, spiders, and mites.

diverticula

pouches or sacs in the lining of the intestine that cause diverticulitis if the sacs become inflamed.

stomach

pouchlike structure at the end of the esophagus.

compression

putting pressure on a body region.

Thalassemia

red blood cells are not formed or functioning properly, and the globulin gene arrangement is affected.

Erythrocytes

red blood cells that are formed in the bone marrow.

See Also

refers the coder to another location in the Alphabetic Index when the initial listing does not contain all the necessary information to select an accurate code.

Malignant primary

refers to the originating site of a malignant tumor

Malignant secondary

refers to the site of tumor metastasis

Biopsy

removal of tissue or cells for pathological examination.

Escherichia coli (E. coli)

rod-shaped bacillus found in the large intestine of humans.

Diplococci bacteria are:

round, spherical, or coffee bean-shaped bacteria that occur in pairs.

accessory organs

salivary glands, liver, gallbladder, pancreas, appendix

prostate gland

secretes fluid that is part of the semen and also aids in the motility of the sperm in the male.

Thyroid gland

secretes hormones that regulate growth and metabolism.

Anxiolytics

sedative that relieves anxiety.

medicaments

term for medicine.

pressure ulcers

sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as decubitus ulcer, pressure sore, or bedsore.

pressure sores

sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as decubitus ulcer, pressure ulcer, or bedsore.

legally induced abortion

termination of a pregnancy that is done by medical personnel working within the law.

Non-essential modifiers

terms located within parentheses () stating supplemental words to a diagnostic term **These terms do not affect the code ** If provider stated these terms or not has no bearing on the diagnosis term.

Cataracts

the abnormal loss of transparency of the lens of the eye.

decubitus ulcer

sore resulting from continuous pressure in an area that eventually limits or stops circulation and oxygen flow to an area; also known as pressure sore, pressure ulcer, or bedsore.

jejunum

starts at the end of the duodenum and is the middle section of the small intestine.

Stapes

stirrup-shaped bone that is part of the middle ear; one of the auditory ossicles.

Hypoparathyroidism

the abnormal or insufficient secretion of parathyroid hormone by the parathyroid glands, caused by a primary parathyroid dysfunction or elevated serum calcium level.

placentia previa

the abnormal positioning of the placenta in the lower uterus so that the cervical os is partially or completely covered.

urinary tract infection (UTI)

the abnormal presence of microorganisms in the urine.

reduction

the act of putting something back into its proper place.

Adult onset diabetes

the body is unable to produce sufficient amounts of insulin within the pancreas; patient might be insulin dependent or not; also known as Type II diabetes.

Immune system

the body's defense mechanism against disease and other foreign materials.

fissured fracture

the bone has a narrow split that does not go through to the other side.

External auditory meatus

the canal that allows sound waves to travel to the inner part of the ear; also known as the external auditory canal.

External auditory canal

the canal that allows sound waves to travel to the inner part of the ear; also known as the external auditory meatus.

Drug dependence

the chronic use of drugs that creates a compulsion to take them in order to experience their effects.

ulcerative colitis

the colon becomes inflamed, and ulcers develop in the lining of the intestine.

thrombolyctic therapy

the intravenous administration of thrombolytic agents, often completed to open the coronary artery occlusion and to restore blood flow to the cardiac tissue.

Encopresis

the involuntary passage of feces.

ileum

the last part of the small intestine, starting at the end of the jejunum.

end-stage renal disease (ESRD)

the late stage of chronic renal failure.

subcutaneous

the layer of skin that connects to the muscle surface.

Granularity

the level of detail.

Eyelids, upper and lower

the lids that protect the eyes and help to keep the surface of the eyeball lubricated

Plasma

the liquid portion of the blood, without its cellular elements.

Emphysema

the loss of lung function due to progressive decrease in the number of alveoli in the bronchus of the lung.

paralysis

the loss of sensation or voluntary motion.

lungs

the main organs of the respiratory system.

penis

the male organ that functions in both the urinary and reproductive systems.

Tympanic cavity

the middle ear found in the temporal bone and housing the auditory ossicles and the eustachian tube.

Von Willebrand's disease

the most common of the hereditary bleeding disorders, in which the clotting process is not working properly.

Retina

the nerve cell layer of the eye that changes light rays into nerve impulses.

Optic nerve

the nerve that carries neural impulses from the eye to the brain

uterus

the organ that sits above the cervix and houses a fetus until birth.

Pericardium

the outer layer of the heart.

Central nervous system (CNS)

the part of the nervous system made up of the brain and spinal cord.

Peripheral nervous system (PNS)

the part of the nervous system that directly branches off the central nervous system.

Autonomic nervous system

the part of the nervous system that regulates the activities of the cardiac muscle, smooth muscle, and glands.

puerperium

the postpartum period beginning from birth until 6 weeks after birth.

abrupto placentae

the premature sudden separation of the placenta from the uterus prior to or during labor.

Systolic Blood Pressure (SBP)

the pressure on the arterial walls during heart muscle contraction.

diastolic blood pressure

the pressure on the arterial walls during relaxation of the heart muscle.

Metabolism

the rate at which energy is used by the body and at which body functions occur.

symptoms

the reason that brings a patient to seek medical attention; the subjective information.

Osteoporosis

the reduction in bone mass that is responsible for different conditions affecting a person's health.

Gastroesophageal reflux disease (GERD)

the reflux of stomach acid and pepsin into the esophagus, causing inflammation.

Sequela (late effect)

the residual effect (condition produced) after the acute phase of an illness or injury has terminated.

herniated disc

the result of the rupture of the nucleus pulposus, or the material in the center of the disc.

depressed fracture

the skull bone is broken and pushed inward.

hiatal hernia

the sliding of part of the stomach into the chest cavity.

Viruses

the smallest of infectious pathogens.

duodenum

the start of the small intestine at the end of the stomach.

Utricle

the structure of the inner ear that aids in maintaining balance.

acute kidney faliure

the sudden interruption of kidney function.

transient hypertension

the synonymous term used to describe elevated blood pressure.

Resiratory system

the system containing structures that exchange oxygen and carbon dioxide in the body.

urinary system

the system that maintains the balance of the contents of the fluids in the body.

Nonessential modifiers

the terms found in the parentheses that do not change code assignment.

dermis

the thick layer of tissue located directly below the epidermis.

Auditory ossicles

the three small bones that transmit sound waves.

gallbladder

stores bile secreted by the liver.

Hallucinogens

substances that induce a perception of visual image or a sound that is not present.

Host

supports a parasite.

Encapsulated

surrounded by a capsule; confined to an area within a capsule; not able to metastasize.

Ceruminous glands

sweat glands found in the external auditory canal.

Thyrotoxic storm

symptoms of hyperthyroidism that are so severe as to threaten the patient's life; also known as thyrotoxic crisis.

Thyrotoxic crisis

symptoms of hyperthyroidism that are so severe as to threaten the patient's life; also known as thyrotoxic storm.

bursa

synovial-fluid-filled sac that works as a cushion to assist in movement.

Hypothyroidism

the thyroid is not operating as efficiently as it could be due to a deficiency of hormone secretion.

Hyperthyroidism

the thyroid is producing excessive amounts of thyroid hormones.

antepartum

the time before childbirth.

menopause

the time in a woman's life when her menstrual cycle ceases.

premenopausal

the time right before menopause.

Nervous system

system that controls all bodily activities and is made up of the central nervous system and the peripheral nervous system.

Drug abuse

taking drugs to excess but not having a dependence on them.

underdosing

taking less of a medication than what is prescribed or instructed by the physician or the manufacturer, whether deliberately or inadvertently.

perinatal period

the time surrounding the birth of the child and up to 28 days after birth.

Organ of Corti

the true organ of hearing found in the cochlea.

Entropion

the turning inward of the border of the eyelid against the eyeball.

Tumors

the uncontrolled abnormal growth of cells; also called a neoplasm.

Neoplasms

uncontrolled abnormal growth of cells; also called tumors.

ureters

very narrow tubes that conduct urine from the kidneys to the bladder.

veins

vessels that carry deoxygenated blood from the body back to the heart.

Arteries

vessels that carry oxygen-rich blood from the heart to the body.

Oval window

what separates the middle ear and inner ear.

Rumination disorder of infancy

when a person regurgitates and chews previously swallowed food.

postmenopausal

when a woman has not had a period for at least 1 year until the time she celebrates her 100th birthday.

perimenopausal

when symptoms of menopause begin.

Polymorphonuclear neutrophils

white blood cells found in the peripheral blood.

Leukocytes

white blood cells that protect the body from disease.

childbirth

the delivery of one or more infants.

Diseases of the Respiratory System Category Codes

- Acute Upper Respiratory Infections (Category Codes J00-J06) - Acute Upper Respiratory Infections (Category Codes J00-J06) - Influenza and Pneumonia (Category Codes J09-J18) - Other Acute Lower Respiratory Infections (Category Codes J20-J22) Other Diseases of Upper Respiratory Tract (Category Codes J30-J39) - Chronic Lower Respiratory Diseases (Category Codes J40-J47) Lung Diseases Due to External Agents (Category Codes J60-J70) - Other Respiratory Diseases Principally Affecting the Interstitium (Category Codes J80-J84) - Suppurative and Necrotic Conditions of the Lower Respiratory Tract (Category Codes J85-J86) - Other Diseases of the Pleura (Category Codes J90-J94) and Intraoperative and Postprocedural Complications and Disorders of Respiratory System, Not Elsewhere Classified (Category Code J95) - Other Diseases of the Respiratory System (Category Codes J96-J99)

Diseases of the Circulatory System Category Codes

- Acute and Chronic Rheumatic Fever (Category Codes I00-I09) - Ischemic Heart Diseases (Category Codes I20-I25) - Pulmonary Heart Disease and Diseases of Pulmonary Circulation (Category Codes I26-I28) - Other Forms of Heart Disease (Category Codes I30-I52) - Cerebrovascular Diseases (Category Codes I60-I69) - Cerebrovascular Diseases (Category Codes I60-I69) - Diseases of Veins, Lymphatic Vessels, and Lymph Nodes, Not Elsewhere Classified (Category Codes I80-I89) - Other and Unspecified Disorders of the Circulatory System (Category Codes I95-I99)

Tissue of Origin & Benign Neoplasms:

- Adipose: Lipoma - Blood vessel: Hemangioma - Bone: Osteoma - Bone marrow: none - Breast: none - Cartilage: Chondroma - Cervix: none - Colon: none - Esophagus: none - Fibrous: Fibroma - Ganglion cells: Ganglioneuroma - Kidney: none - Lung: none - Meninges: Meningioma - Muscle tissue, smooth: Leiomyoma - Muscle tissue, striated: Rhabdomyoma - Nerve tissue: Neuroma Neurinoma; Neurofibroma - Ovaries: none - Penis: none - Skin: none - Stomach: none - Testes: none - Uterus: Fibroid

Tissue of Origin & Malignant Neoplasms:

- Adipose: Liposarcoma - Blood vessel: Hemangiosarcoma -Bone: Osteogenic sarcoma; Osteosarcoma - Bone marrow: Ewing sarcoma; Multiple myeloma; Leukemia - Breast: Carcinoma of breast - Cartilage: Chondrosarcoma - Cervix: Epidermoid carcinoma of the cervix - Colon: Carcinoma of colon - Esophagus: Esophageal adenocarcinoma - Fibrous: Fibrosarcoma - Ganglion cells: Neuroblastoma - Kidney: Hypernephroma Wilms' tumor - Lung: Adenocarcinoma of the lung; Oat cell carcinoma - Meninges: Malignant meningioma - Muscle tissue, smooth: Leiomyosarcoma - Muscle tissue, striated: Rhabdomyosarcoma - Nerve tissue: Neurogenic sarcoma - Ovaries: Cystadenocarcinoma of the ovaries - Penis: Carcinoma of penis - Skin: Basal cell carcinoma - Stomach: Gastric adenocarcinoma; Melanoma; Squamous cell carcinoma - Testes: Seminoma - Uterus: Adenocarcinoma of the uterus

Sepsis & Severe Sepsis Sequencing:

- Admission: underlying infection is principle followed by R65.2 code - Not present on admission: reason for encounter is primary, underlying infection and R65.2 are secondary - Present but not confirmed at admission: query the provider - Sepsis with localized infection at admission: underlying infection assigned first, then localized infection secondary * If severe sepsis, code R65.2 is additional * Patient is admitted for infection (i.e.: pneumonia) code infection first, then sepsis codes

Common Parasitic Infections Name of Infection & Common Pathogen

- African sleeping sickness: Trypanosoma gambiense - Chagas' disease: Trypanosoma cruzi - Malaria: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, or Plasmodium ovale - Pinworm: Enterobius vermicularis - Head lice: Pediculus Capitis - Scabies: Sarcoptes

Common Yeast and Molds That Affect Humans Name of Infection & their Common Pathogen

- Athlete's foot: Tinea pedis - Thrush: Candida albicans - Ringworm: Tinea capitis - Chicago disease (A fungus that lives in the environment, particularly in moist soil and in decomposing matter such as wood and leaves.): Blastomyces dermatitidis

Additional B Codes and Descriptions:

- B50-B64 Protozoal disease: This code block includes plasmodium malaria, other specified forms of malaria, leishmaniasis, African trypanosomiasis, Chagas' disease, and toxoplasmosis. - B65-B83 Helminthiasis: This code block includes locate echinococcosis, filariasis, trichinellosis, and other intestinal helminthiases. - B85-B89 Pediculosis, acariasis, and other infestations: Pediculosis, also known as lice, is coded to this code range, as are scabies, myiasis, and acariasis. Acariasis is an infestation with mites or acariads. - B90-B94 Sequelae of infectious and parasitic diseases: This code range is used to indicate conditions in categories A00-B89 as the cause of sequelae that are classified elsewhere. The "Note" and "Code first" instructional notations, that appears in the Tabular Listing of ICD-10-CM block heading B90-B94, need to be reviewed prior to code selection. Also included are residuals of diseases classifiable to the same categories (A00-B89) if there is documented evidence that the disease no longer exists. - B95-B97 Bacterial and viral infectious agents B99 other infectious diseases: Categories B95 to B97 are used as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere to identify the specific organism present. Category B99 reports other infectious diseases and unspecified infectious diseases.

Use, abuse& dependence hierarchy of SAME substance:

- Based on the provider's documentation - Use & Abuse, assign ABUSE - Abuse & Dependence, assign DEPENDENCE - Use, Abuse, & Dependence, assign DEPENDENCE - Use & Dependence, assign DEPENDENCE - .Unspecified code use, add .9 at the end of category code (beginning with the letter F).

Diseases of the Digestive System Category Codes

- Diseases of the Oral Cavity and Salivary Glands (Category Codes K00-K14) - Disease of Esophagus, Stomach, and Duodenum (Category Codes K20-K31) - Diseases of Appendix (Category Codes K35-K38) - Hernia (Category Codes K40-K46) - Noninfective Enteritis and Colitis (Category Code K50-K52) - Other Diseases of the Intestines (Category Codes K55-K64) - Diseases of Peritoneum and Retroperitoneum (Category Codes K65-K68) - Disease of Liver (Category Codes K70-K77) - Disorders of Gall Bladder, Biliary Tract, and Pancreas (Category Codes K80-K87) - Other Diseases of the Digestive System (Category Codes K90-K95)

Common Addictive Drugs Hallucinogens

- Ecstasy; methylenedioxymethamphetamine (MDMA) - Ketamine - LSD; lysergic acid diethylamide - Marijuana - MDA; methylenedioxymethamphetamine - Mushrooms - PCP; Phencyclidine (street names: Angel dust, boat, hog, love boat, wack, ozone, peace pill, dust, embalming fluid, rocket fuel) - Peyote - XTC

Coding of Mental, Behavioral, and Neurodevelopmental Disorders; F01-F09:

- F01: used to classify vascular dementia and includes arteriosclerotic dementia. Code first the underlying physiological condition or sequelae of cerebrovascular disease. - F02: Dementia in other diseases classified elsewhere is classified here. Code first the underlying physiological condition, such as Alzheimer's, cerebral lipidosis, epilepsy, and recurrent seizures, to name a few that are listed. - F03: Examples of diagnoses that are classified to F03 include: Presenile dementia, Presenile psychosis, Primary degenerative dementia, Senile dementia, Senile dementia, depressed or paranoid type, Senile psychosis. - F04: Amnestic disorders due to known physiological conditions are classified to category F04. This includes nonalcoholic Korsakov's psychosis or syndrome. The underlying physiological condition that caused the amnestic disorder should also be coded and listed first, as instructed by the coding notation. - F05: Delirium due to a known physiological condition is classified to F05. This code is used for: Acute or subacute brain syndrome, Acute or subacute confusional state (nonalcoholic), Acute or subacute infective psychosis, Acute or subacute organic reaction, Acute or subacute psycho-organic syndrome, Delirium of mixed etiology, Delirium superimposed on dementia, and Sundowning. Code first the underlying physiological condition as well as the Excludes1 and Excludes2 notes that appear in the codebook. - F06: Other mental disorders due to known physiological condition. Differentiated at the fourth and fifth character levels to indicate catatonic, psychotic, mood, anxiety, and other specified mental disorders due to known physiological conditions. The coder should be guided by the numerous Excludes1 and Excludes2 notes that appear at the code levels within this category. F07: personality and behavioral disorders due to known physiological conditions. The fourth and fifth characters are used to define the specific disorders. Coders are instructed to Code first the underlying physiological condition for codes assigned. F09: Unspecified mental disorder due to known physiological condition, is used to code: Mental disorder NOS due to known physiological condition, Organic brain syndrome NOS, Organic mental disorder NOS, Organic psychosis NOS, and Symptomatic psychosis NOS. Code first the underlying physiological condition.

Schizophrenia, Schizotypal, Delusional, and Other Non-Mood Psychotic Disorders (Category Codes F20-F29)

- F20: Schizophrenia. Differentiated at the fourth-character level to include: paranoid schizophrenia, disorganized schizophrenia, catatonic schizophrenia, undifferentiated schizophrenia, residual schizophrenia, and other forms. - F21: Schizotypal disorder including: Borderline schizophrenia, Latent schizophrenia, Latent schizophrenic reaction, Prepsychotic schizophrenia., Prodromal schizophrenia, Pseudoneurotic schizophrenia, Pseudopsychopathic schizophrenia, & Schizotypal personality disorder. - F22: Delusional disorders. - F23: Brief psychotic disorders, includes paranoid reactions & psychogenic paranoid psychosis. - F24: classifies shared psychotic disorder and includes folie à deux, induced paranoid disorder, and induced psychotic disorders. - F25: Schizoaffective disorders. Defined at the fourth-character level to identify the various types of schizoaffective disorders that include bipolar type, depressive type, and other forms. - F28: Other psychotic disorders not due to a substance or known physiological condition are classified to this category. A diagnosis of chronic hallucinatory psychosis is coded here. - F29: Unspecified psychosis not due to a substance or known physiological condition. The diagnosis of psychosis is coded here.

Additional codes for routine gynecological examinations:

- For screening for human papillomavirus, if applicable, (Z11.51) - For screening vaginal pap smear, if applicable (Z12.72) - To identify acquired absence of uterus, if applicable (Z90.71-)

Viral Infections Characterized by Skin and Mucous Membrane Lesions (Category Codes B00-B09) Viral infections included:

- Herpes viral [herpes simplex] infections (category B00) - Varicella, commonly known as chickenpox (category B01) - Zoster [herpes zoster] (category B02) - Smallpox (category B03) - Monkeypox (category B04) - Measles (category B05) - Rubella [German measles] (category B06) - Viral warts (category B07) - Other viral infections characterized by skin and mucous membrane lesions, not elsewhere classified (category B08) - Unspecified viral infection characterized by skin and mucous membrane lesions (category B09) **Please note that for many categories the codes are differentiated to identify the site that is impacted by the viral infection or the site of a complication.

Certain infectious and parasitic diseases (Block Title Category Codes) Intestinal infectious diseases:

- Intestinal infectious diseases: A00-A09 - Tuberculosis: A15-A19 - Certain zoonotic bacterial diseases: A20-A28 - Other bacterial diseases: A30-A49 -Infections with a predominantly sexual mode of transmission: A50-A64 - Other spirochetal diseases: A65-A69 - Other diseases caused by chlamydiae: A70-A74 - Rickettsioses: A75-A79 - Viral and Prion infections of the central nervous system: A80-A89 - Arthropod-borne viral fevers and viral hemorrhagic fevers: A90-A99 - Viral infections characterized by skin and mucous membrane lesions: B00-B09 - Other human herpesviruses: B10 - Viral hepatitis: B15-B19 - Human immunodeficiency virus [HIV] disease: B20 - Other viral diseases: B25-B34 - Mycoses: B35-B49

Malignant Versus Benign Neoplasms:

- Malignant neoplasms are also called cancer (carcinoma, lymphoma, melanoma, sarcoma). - Benign neoplasms usually grow slowly, typically are encapsulated (surrounded by a capsule), & do not metastasize - Both benign and malignant neoplasms are named and classified by the tissue of origin.

Coding of Neoplasms

- Malignant neoplasms: In situ neoplasms,C00-C96, C7A, and C7B - Carcinoma in situ, ca in situ, or CIS: D00-D09 - Benign neoplasms,: D10-D36 and D3A - Neoplasms of uncertain behavior, D37-D48 - Neoplasms of unspecified behavior, D49

Coding & Sequencing Complications

- Management of only anemia: malignancy code is primary, anemia secondary - Management of anemia due to chemo, immuno, or radiation therapies: anemia is primary; neoplasm secondary; adverse effect (T45.1X5 - for chemo/immuno therapy) or (Y84.2 - radiation) additional - Management of only dehydration due to neoplasm: dehydration is first, neoplasm/malignancy secondary - Treatment of surgical complication: complication is principle if treatment is to resolve complication.

Mycoses (Category Codes B35-B49) Common sites:

- Mouth (commonly called thrush), B37.0 - Skin and nails (commonly called candidial onychia), B37.2 - Vulva and vagina (commonly called candidial or monilial vulvovaginitis), B37.3

Disorders of the Skin: (W/ IMAGE)

- NONPALPABLE: Macule, Patch - PALPABLE: Papule, Plaque, Nodule, Wheal - FLUID-FILLED CAVITIES W/IN THE SKIN: Vesicle, Bulla, Pustule

Query the provider if (Sepsis)

- Negative or inconclusive blood cultures - if "urosepsis" is documented. (more information is needed)

Other Diseases Caused by Chlamydiae (Category Codes A70-A74) Diseases include:

- Parrot Fever - Trachoma - Chlamydial diseases, such as chlamydial peritonitis and chlamydial conjunctivits

Infectious intestinal diseases can be caused by a number of organisms. Treatment:

- Patients are given an antiemetric drug to reduce the vomiting. - Antimotility drugs are used to relieve the abdominal pain. - To replace lost fluids, patients are encouraged to increase fluid intake. - In severe cases, patients are given IV replacement therapy. Antibiotics are given to treat the organism present.

Von Willebrand's disease, also known as angiohemophilia Treatment:

- Patients diagnosed with von Willebrand's disease are to avoid using aspirin because it exacerbates bleeding. - Patients who have lost a significant amount of blood will have a transfusion of plasma cryoprecipitate. - Antifibrinolytic agents are administered to patients during surgery and dental procedures to decrease bleeding. - Desmopressin acetate is also given to patients to control the disease.

Opportunistic infections commonly occur in the following types of individuals:

- Patients with chronic conditions, such as AIDS, diabetes, and cancer - Infants and newborns - Patients who are postsurgery - Patients who have taken antibiotics - Steroid users

Other Human Herpesviruses (Category Code B10)

- Read the Excludes2 note under the category heading for B10. - Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but if a patient has both conditions at the same time it is acceptable to use both the code and the excluded code together.

Symptoms caused in various body symptoms in patients using (ENDS):

- Respiratory symptoms—cough, chest pain and shortness of breath - Gastrointestinal symptoms—abdominal pain, diarrhea, nausea, and vomiting - Additional symptoms—fever, chills and weight loss.

Common Viral Infections Name of Disease & Name of Pathogen

- Shingles: Herpes zoster - Chickenpox: Varicella - AIDS: Human immunodeficiency virus - Genital herpes: Herpes simplex - German measles: RNA virus - West Nile virus: Flavivirus

Infectious mononucleosis Treatment:

- Steroid therapy is common. - Symptomatic treatment includes over-the-counter pain relievers and throat gargles using warm saline, adequate hydration, nonaspirin analgesics, and antipyretics. - For severe anemia or thrombocytopenia, transfusions are given. - For splenic rupture, a splenectomy is indicated.

Gustilo Classification of Fractures, types III subtypes:

- Subtype IIIA Adequate soft tissue coverage despite soft tissue laceration, or flaps, or high-energy trauma Includes segmental fractures or severely comminuted fractures - Subtype IIIB Extensive tissue damage with periosteal stripping, bone exposure, or a vascular injury requiring repair Usually accompanied by mass contamination - Subtype IIIC Major arterial (vascular) damage and injury Repair of injury necessary to salvage limb

Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, followed by code(s):

- T38.3x6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. **Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned. - T38.3x1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional).

Septic shock requires multiple codes. What are those codes?

- Underlying systemic infection (first) - R65.21 or T81.12 depending on circumstances of septic shock documented (second) - Additional codes for other acute organ dysfunctions

Sever Sepsis requires a minimum of two (2) codes. What are these codes?

- Underlying systemic infection (unknown organism code A41.9)(first) - Severe sepsis code subcategory (R65.2)(second) ** Additional codes for associated organ dysfunction

B codes are used to report:

- Viral infections characterized by skin and mucous membrane lesions, categories B00-B09 - Other Human herpesviruses, category B10 - Viral hepatitis, categories B15-B19 - Human immunodeficiency virus (HIV) disease, category B20 - Other viral diseases, categories B25-B34 - Mycoses, categories B35-B49 -Protozoal diseases, categories B50-B64 - Helminthiases, categories B65-B83 - Pediculosis, acariasis, and other infestations, categories B85-B89 - Sequelae of infectious and parasitic diseases, categories B90-B94 - Bacterial and viral infectious agents, categories B95-B97 - Other infectious diseases, category B99

Viral hepatitis Clinical Testing:

- White blood cell count in the normal to low range - Abnormal liver tests showing that especially markedly elevated aminotransferases are present early in the course of the disease - Biopsy of the liver showing hepatocellular necrosis and mononuclear infiltrates - Mild proteinuria and bilirubinuria

Respiratory and Cardiovascular Disorders Specific to the Perinatal Period (Category Codes P19-P29)

- metabolic acidemia in the newborn (P19) - respiratory distress of the newborn (P22) - congenital pneumonia (P23) - neonatal aspiration (P24) - interstitial emphysema and related conditions originating in the perinatal period (P25) - pulmonary hemorrhage (P26) - chronic respiratory disease (P27) - other respiratory conditions (P28) - cardiovascular disorders that originated in the perinatal period (P29)

Functions the blood performs in the body:

- transports oxygen from the lungs to the cells and then moves waste from the cells to organs that dispose of the waste. - transports various nutrients throughout the body. - different fluids and electrolyte balance are maintained by the flow of the blood through the body. - the interior of the body is protected from infection by ability of the blood to clot, thereby keeping out infection and also preventing death due to excessive blood loss.

Code Format used in ICD-10-CM

1. 3-7 digits create a diagnostic code 2. Categories are the first 3 digits. ( Consist of alpha and numerical digits, the first digit is alphabetic) 3. Subcategories are 4-5 characters; with further digits representing codes 4. placeholder [X] is used for future expansion or a code that has expanded. (- 7th characters may be required on some codes within a category or as noted in a table. - This character is always 7th - so a placeholder X may be required for digit 5/6.)

External Cause Hierarchy of Priority:

1. Child Abuse 2. Terrorism 3. Cataclysmic Events 4. Transport Events ** Then assign activity and status codes***

Documentation

1. Code assignment is based upon the provider's documentation. EXCEPT: BMI (body mass index); depth of non-pressure chronic ulcers; pressure ulcer stages; coma stage; stroke scale. Any associated diagnosis (overweight, ulcer) must be documented by the provider.

These require two (2) codes

1. Etiology 2. Manifestations 3. May be required for sequela, complication codes, or obstetric codes

alphabetic listing of terms and corresponding codes in the ICD-10-CM

1. Index to Diseases and Injuries 2. Index to External Causes of Injury

The four types of conventions are used in ICD-10-CM to provide guidance to the coder:

1. Instructional notes 2. Punctuation marks 3. Abbreviations 4. Symbols

Steps for accurate coding:

1. Locate the Main Term in the Alphabetic Index. (The main term is the condition that is present). 2. Scan the Main Term Entry for Any Instructional Notations. (If a notation is present, follow it.) 3. In the Diagnostic Phrase Being Coded, Identify Any Terms That Modify the Main Term. (Terms that serve as modifiers in this example are chronic and allergic.) 4. Follow Any Cross-Reference Notes. (Cross-references appear in the form of instructional notes such as See.) 5. Always Verify the Code in the Tabular List. (After selecting a code from the Alphabetic List, the coder must always verify the code in the Tabular List [colored pages/chapters]) 6. Follow Any Instructional Terms. After turning to the Tabular list, scan for any instructional terms that may be present. 7. Select the Code. After completing these steps, the coder can now select the code but should scan the code selected to ensure that the most specific one has been selected.

Sequela (late effect)

1. Residual effect with no time limit of when a sequela begins. 2. Requires 2 codes (condition or nature of sequela, 1st; the sequel, 2nd). EXCEPT: when a code for a sequel includes a manifestation code.

Normal Stages of Blood Clotting

1. Vessel cut 2. Hemorrhage (Aggregation of platelets 3. Thromboplastin / Prothrombin 4. Thrombin / Fibrinogen 5. Fibrin 6.Red cells enmeshed in fibrin (Red cells/Platelets) ** See image

Default Codes:

1. code listed next to a main term in the alphabetic index. 2. condition that is most commonly associated with the main term or is the unspecified code for the condition.

Combination codes (as one code):

1. describe 2 diagnoses 2. diagnosis with associated manifestation 3. diagnosis with associated complication

Default Codes are used:

1. if there are no other options to chose from 2. cannot find the specific code in the book

Medical Coding Revenue Cycle

1. patient makes the appointment 2. patient is seen for services 3. information is coded 4. diagnosis (ICD-10-CM) 5. bill a procedure 6. bill to the insurance company/companies (Healthcare Reimbursement) 7. Follow up to make sure everything is filed and has been paid properly

Infectious and parasitic diseases are coded in one of three ways. What are the:

1. single-code assignment 2. combination-code assignment 3. dual-code assignment

How many standards of ethical principles are there?

11

Trimesters are counted from the first day of the last menstrual period. They are defined as follows:

1st trimester—less than 14 weeks 0 days 2nd trimester—14 weeks 0 days to less than 28 weeks 0 days 3rd trimester—28 weeks 0 days until delivery

Viral Infections of the Central Nervous System (Category Codes A80-A89) and Arthropod-borne Viral Fevers and Viral Hemorrhagic Fevers (A90-A99) Viral infections include:

Acute poliomyelitis Rabies Mosquito-borne viral encephalitis Tick-borne viral meningitis

Symptoms of Covid-19 typically appear:

2-14 days after exposure to the virus

Pedestrian Injured in Transport Accident Seventh Characters:

A, Initial encounter D, Subsequent encounter S, Sequela

Certain infectious and parasitic diseases coding range:

A00-B99

Code for underlying systemic infection for sepsis. If the organism is not known, use code:

A41.9

Who approved the most recent version of the AHIMA Standards of Ethical Coding?

AHIMA House of Delegates

Abbreviations that are associated with chapter 6 of ICD-10-CM include:

AIDS: acquired immunodeficiency syndrome C&S: culture and sensitivity (test) EBV: Epstein-Barr virus E. coli: Escherichia coli hep: : hepatitis HAV: Hepatitis A HBV: Hepatitis B HCV: Hepatitis C HDV-delta: Hepatitis D HEV: Hepatitis E HIV: human immunodeficiency virus mono: mononucleosis polio: poliomyelitis staph: staphylococcal bacteria strep: streptococcal bacteria TB: tuberculosis

The following abbreviations are commonly associated with neoplasms:

ALL = acute lymphoblastic leukemia AML = acute myelogenous leukemia BCE = basal cell epithelioma BMA = bone marrow aspiration BSE = breast self-exam Bx = biopsy Ca, CA = cancer, carcinoma CA-125 = ovarian carcinoma antigen (tumor marker-ovary) CEA = carcinoembryonic antigen (tumor marker-colon, lung, breast, others) Chemo = chemotherapy PSA = prostate-specific antigen (tumor marker-prostate) TNM = tumor, nodes, metastasis (refers to tumor staging)

The following abbreviations are commonly used for the eye and adnexa:

ARMD = age-related macular degeneration EOM = extraocular movement IOL = intraocular lens IOP = intraocular pressure OD = right eye Ophth = ophthalmology OS = left eye OU = both eyes PERRLA = pupils equal, round, reactive to light, and accommodation

What is the purpose of the definitions section?

Achieve clarity without needless repetition

Z codes are located in the Alphabetic Index by referencing a main term. Main terms that are used to locate Z codes include:

Admission Aftercare Attention to Chemotherapy Counseling Encounter for Examination Fitting History of Maintenance Observation Problem Replacement Resistance Screening Vaccination

Admissions and Encounters Involving Surgery, Chemotherapy, Immunotherapy, and Radiation Therapy

After a patient has been diagnosed with a malignant condition, treatment options can include surgery, chemotherapy, immunotherapy, radiation therapy, or a combination of treatments. A coder must identify the treatment occurring during the current encounter or admission.

Common Addictive Drugs Benzodiazepines

Ambien; zolpidem Ativan; lorazepam Dalmane; flurazepam Halcion; triazolam Klonopin; clonazepam Librium; chlordiazepoxide Restoril; temazepam Serax; oxazepam Tranxene (Tran-zee-ne); clorazepate Valium; diazepam Versed; midazolam Xanex; alprazolam

Common Addictive Drugs Stimulants

Amphetamine diet pills Cocaine Dexedrine Ephedrine Methamphetamine Pseudoephedrine Ritalin; methylphenidate

Common Addictive Drugs Barbiturates

Amytal; amobarbital Fiorinal; butalbital Nembutal; pentobarbital Phenobarbital Seconal; secobarbital

Ischemic Heart Disease: The vessels commonly become blocked or constricted because of the presence of fatty deposits on the walls of the arteries. Ischemic heart disease is also referred to as: (name all 7)

Arteriosclerotic coronary artery disease (ACAD) Arteriosclerotic heart disease (ASHD) Atherosclerosis Coronary artery disease (CAD) Coronary arteriosclerosis Coronary heart disease Coronary ischemia

Pain

As the malignancy progresses and as treatment occurs, cancer patients sometimes experience pain that can result in depression, anxiety, difficulty sleeping, and loss of appetite. Narcotic medications may be necessary to control the pain. If a patient seeks medical care or is admitted for control of the pain, the malignancy code is designated as the principal diagnosis.

Other Viral Diseases (Category Codes B25-B34) Includes:

B25 Cytomegaloviral disease B26 Mumps B27 Infectious mononucleosis B30 Viral conjunctivitis B33 Other viral diseases, not elsewhere classified- such as epidemic myalgia, Ross River disease, viral carditis, retrovirus infections, not elsewhere classified, Hantavirus (cardio)-pulmonary syndrome [HPS] [HCPS], and other specified viral diseases. B34 Viral infection of unspecified site

Category B34 contains the following codes:

B34.0 Adenovirus infection, unspecified. B34.1 Enterovirus infection, unspecified, including Coxsackievirus infection NOS and Echovirus infection NOS. B34.2 Coronavirus infection, unspecified. Reference the ICD-10-CM tabular listing for code B34.2. Note the ** * * Excludes1 note that reads as follows: ** Excludes1: COVID-19 (U07.1) *** pneumonia due to SARS-associated coronavirus (J12.81)

COVID-19 and pneumonia due to SARS-associated coronavirus is not reported with a code from category B34 and is reported with the codes:

B34.3 Parvovirus infection, unspecified. B34.4 Papovavirus infection, unspecified. B34.8 Other viral infections of unspecified site. B34.9 Viral infection, unspecified.

Common Addictive Drugs Others

Benadryl; Diphenhydramine Chloral hydrate Flexeril; Cyclobenzaprine Miltown; Meprobamate Placidyl; Ethchlorvynol Skelaxin; Metaxalone Soma; Carisoprodol

Infectious intestinal diseases can be caused by a number of organisms. Clinical Testing:

Blood and stool cultures to identify the type of infectious organisms

Certain Zoonotic Bacterial Diseases (Category Codes A20-A28): Diagnosis:

Blood specimens

Common Addictive Drugs Opiates (Opiods)

Buprebidnex; buprenorphine Darvon, Darvocet; propoxyphene Demerol; meperidine Dilaudid; hydromorphone Fentanyl Heroin Immodium; loperamide Lomotil; diphenoxylate Lorcet; hydrocodone & acetaminophen MS Contin/morphine Methadone; Dolophine, Dolobid **LAAM (Orlaam); levomethadyl Nubain; nalbuphine NyQuil, cough syrup; dextromethorphan OxyContin; oxycodone Percocet; Percodan Stadol; butorphanol Talwin; pentazocine Ultram; tramadol Vicodin; hydrocodone

T31:

Burns: Used when the site of the burn is not specified or when there is a need for additional data

Disseminated means a patient has cancer all over, what code is used?

C80.0

Unknown cancer code used when there is no determination of primary site. Rarely used in an inpatient setting because they can do tests to determine where the origin is

C80.1

The following abbreviations are commonly associated with the blood and blood-forming organs:

CBC = complete blood count ESR = erythrocyte sedimentation rate Hct = hematocrit Hgb = hemoglobin MPV = mean platelet volume RBC = red blood cells sed rate = erythrocyte sedimentation rate WBC = white blood cells

High risk factors for Covid-189:

Cancer Heart disease—such as heart failure, coronary artery disease and cardiomyopathies Lung disease—such as COPD Kidney disease Type 2 Diabetes Obesity—BMI of 30 or over Sickle cell disease Weakened immune system from solid organ transplant

Eradication of Malignancy and Follow-Up Examinations

Cancer patients are monitored on a regular basis for recurrence or metastasis. Code selection is based on the status of the patient at the time of the encounter.

Diabetes Mellitus E08-E13

Category E08, Diabetes mellitus due to underlying condition Category E09, Drug or chemical induced diabetes mellitus Category E10, Type 1 diabetes mellitus Category E11, Type 2 diabetes mellitus; default Category E13, Other specified diabetes mellitus

Parts of the Central and Peripheral Nervous Systems

Central: Brain and Spinal cord Peripheral: Peripheral nerves and Sensory receptors

Clinical tests used to diagnosis tuberculosis include:

Chest x-rays Mantoux skin test Sputum culture

reporting code M36.2, Hemophilic arthropathy, the coder should be aware of the following instructional notation:

Code first underlying disease, such as: factor VIII deficiency (D66) with vascular defect (D68.0) factor IX deficiency (D67) hemophilia (classical) (D66) hemophilia B (D67) hemophilia C (D68.1)

If a patient is admitted in their first trimester however was in their second trimester when discharged, how is this coded?

Coding should be done with the trimester the patient was in at admission. (In this example: first)

Iris

Colored part of the eye

T32

Corrosions: Suggested for documentations of 20% or more of the body surface is affected.

Symptoms of Covid-19 are:

Cough Diarrhea Fever or chills Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Shortness of breath or difficulty breathing Congestion or runny nose Nausea and/or vomiting

Nutritional Anemias (D50-D53) codes and descriptions

D50.0: Iron deficiency anemia secondary to blood loss (chronic) is reported with this code. The term posthemorrhagic anemia also codes to this subcategory. D50.1: Sideropenic dysphagia is a type of iron-deficiency anemia that becomes so severe that the patient has difficulty swallowing in addition to the other symptoms of anemia. Also known as Plummer-Vinson syndrome. D50.8: Should the provider document that the patient is iron deficient due to lack of iron in the diet, this is the code assigned. D50.9: This code is reported for other iron-deficiency anemias and is assigned when a more specific code cannot be used.

Vitamin B12 deficiency anemia codes and descriptions

D51.0: This code reports vitamin deficiency anemia due to intrinsic factor deficiency. Diseases coded here include Addison anemia, Biermer anemia, Pernicious (congenital) anemia, and congenital intrinsic factor deficiency. Vitamin deficiency occurs when there is a lack of the protein necessary for the to bond within the cell. D51.1: This code reports vitamin deficiency anemia due to selective vitamin malabsorption with proteinuria. D51.2: Transcobalamin II deficiency is a very rare autosomal recessive disease. Transcobalamin II is necessary to transport vitamin . D51.3-D51.9: This range of codes is used for other vitamin deficiencies, such as dietary vitamin deficiency anemia, vegan anemia, and unspecified vitamin anemia.

Hemolytic Anemias (Category Codes D55-D59)

D56.0: Alpha thalassemia is a condition in which there is a deficiency in the alpha protein being produced. There are four types of alpha thalassemia. The coder must read the diagnostic statement and the code description to be sure the correct code is assigned. It should also be noted that an Excludes1 notation and a notation that directs the coder to "Use additional code..." is found at this code level. D56.1: Beta thalassemia is a condition in which there is a lack of the beta protein being produced. There are various types of beta thalassemia, and verification of the code description is necessary before a code assignment is made. D56.2: Delta-beta thalassemia, as well as homozygous delta-beta thalassemia, is reported using this code. Code assignment is directed by the Excludes1 note. D56.3: This code is used to report diseases such as thalassemia minor, alpha thalassemia trait, beta thalassemia minor, and delta-beta thalassemia minor. Review the code in the Tabular Listing for additional diagnoses reported with this code. The coder should note the Excludes1 note found in the code book for this code. D56.4: Hereditary persistence of fetal hemoglobin (HPFH) is reported with this code. D56.5: Hemoglobin E-beta thalassemia is reported with this code and coders should reference the Excludes1 note for guidance when assigning this code. D56.8: Other thalassemias, including dominant thalassemia, Hemoglobin C thalassemia, mixed thalassemia and thalassemia with other hemoglobinopathy are reported with this code. D56.9: This code reports Thalassemia, unspecified. Mediterranean anemia and Mediterranean anemia with other hemoglobinopathy are reported with this code.

MODULE SIX: Chapter 20: Pregnancy, Childbirth, and the Puerperium Chapter 21: Certain Conditions Originating in the Perinatal Period Chapter 22: Congenital Malformations, Deformations, and Chromosomal Abnormalities Chapter 23: Symptoms, Signs, and Abnormal Clinical Laboratory Findings

FLASH CARDS

Aplastic and Other Anemias and Other Bone Marrow Failure Syndromes (Category Codes D60-D64)

D60.0: Chronic acquired pure red cell aplasia. Pure red cell aplasia is a condition in which precursors to the red blood cells are affected in the bone marrow and eventually cease to be produced. White cells are not affected. D60.1: This code is used to report transient acquired pure red cell aplasia. D60.8: Other acquired pure red cell aplasias are reported using this code. D60.9: This code is used to report acquired pure red cell aplasia in which the documentation does not specify the type of aplasia. Prior to code assignment, the coder should query the provider to see if the disease could be further defined to prevent the assignment of this unspecified code. D61.01: This code is used to report constitutional (pure) red blood cell aplasia which includes Blackfan-Diamond syndrome, red cell (pure) aplasia of infants and primary (pure) red cell aplasia. The other types of red blood cell aplasia that are reported with this code are listed in the code book. It should also be noted that this code has an Excludes1 notation. D61.09: Other constitutional aplastic anemias including Fanconi's anemia and pancytopenia with malformations are reported using code D61.09. D61.1: Drug-induced aplastic anemia is reported with this code. An instructional note appears under the code that instructs the coder to "Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)." D61.2: Aplastic anemia due to other external agents is reported using this code. The coder must also follow the note that instructs the coder to "Code first, if applicable, toxic effects of substances chiefly nonmedicinal as to source (T51-T65)." D61.3:This code reports idiopathic aplastic anemia, which is a condition in which the bone marrow is not able to produce cells properly for unknown reasons. D61.8: Within the D61.8 subcategory, other specified aplastic anemias and other bone marrow failure syndromes are differentiated at the fifth character level with the following codes: D61.81: This subcategory reports Pancytopenia, a condition in which there is a decrease in the number of platelets, white blood cells, and red blood cells. An extensive Excludes1 note appears for this subcategory of codes. The subcategory is differentiated at the sixth character level to identify the various types of pancytopenia. Remember, codes must be reported to the greatest level of specificity. In this case, sixth characters must be reported. D61.82 reports Myelophthisis, a severe form of anemia in which certain bone marrow material shows up in the peripheral blood. Coders should be guided by the "Code also" and the Excludes1 notations that appear for this code. D61.89: Other specified aplastic anemias and other bone marrow failure syndromes are reported with this code. D61.9: Aplastic anemia in which the documentation is unspecified is assigned this code. D62: This code is used to report acute posthemorrhagic anemia and is one of the few three-digit codes in ICD-10-CM. It should be noted that an Excludes1 notation is present for this code. D63.0: Anemia in neoplastic disease is assigned this code. The coder is instructed to code first the neoplasm (C00-D49). Excludes1 and Excludes2 notes also appear for this code. Review the notes prior to code assignment. D63.1: This code is used to report anemia in chronic kidney disease. Coders should be guided by the notation for this code that instructs the coder to "Code first underlying chronic kidney disease (CKD) (N18.-)." D63.8: Anemia in other chronic diseases classified elsewhere is reported with this code. Coders need to be guided by the extensive "Code first" notation that appears in the code book for this code. D64: This category is used to report other types of anemia. The category is further divided at the fourth and sometimes fifth character levels to further differentiate the codes. Coders should also note the various Excludes1 and other notations that appear at various codes.

Coagulation Defects, Purpura, and Other Hemorrhagic Conditions (Category Codes D65-D69)

D65: Disseminated intravascular coagulation (defibrination syndrome) is reported with this code. It should be noted that there are extensive Includes and Excludes1 notes for this code. D66:This code reports hereditary factor VIII deficiency, a form of hemophilia. The hereditary factor diseases noted in this block of codes involve clotting factor problems. D67: This code reports hereditary factor IX deficiency, which includes Christmas disease, factor IX deficiency, hemophilia B, and plasma thromboplastin component deficiency. D68.0: D68.0 reports von Willebrand's disease the most common of the hereditary bleeding disorders. When this disease occurs, the von Willebrand factor is missing from the blood or is not working properly. This factor is essential in the clotting process. D68.1: Hereditary factor XI deficiency, hemophilia C, and Rosenthal's disease are reported with this code. D68.2: Hereditary deficiencies of other clotting factors are reported with this code. The coder should note the extensive list of diseases included in the ICD-10-CM book under the heading for this code. D68.3: This subcategory reports hemorrhagic disorder due to circulating anticoagulants and is divided as follows: D68.31: Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors is reported with this subcategory. It should be noted that six characters are needed to code accurately for this subcategory. This subcategory includes hemorrhagic disorders due to intrinsic increase in antithrombin, anti-VIIIa, anti-IXa, anti-Xa, anti-XIa, and hyperheparinemia. Review ICD-10-CM coding manual for six characters of 1, 2, and 8. D68.32: This code is used to report a hemorrhagic disorder due to extrinsic circulating anticoagulants. The coder must take note of the instructional notation that appears for this code that states "Use additional code for adverse effect, if applicable, to identify drug (T45.515, T45.525)." D68.4: This code reports acquired coagulation factor deficiency, including deficiencies of coagulation factors due to liver disease and vitamin K deficiency. This code does not, however, include a vitamin K deficiency in a newborn. The coder has to reference code P53 for this condition. D68.5: The D68.5 subcategory reports primary thrombophilia, a condition that can be genetic (primary) or acquired. Thrombophilia is a condition in which the patient is predisposed to develop thromboses. ICD-10-CM reports the following codes for the various types of primary thrombophilia: D68.51: Activated protein C resistance D68.52: Prothrombin gene mutation D68.59: Other primary thrombophilia such as antithrombin III deficiency, hypercoagulable state, protein C deficiency, and protein S deficiency are reported using this code. Additional diseases are listed in the code book. D68.61: Antiphospholipid syndrome and Anticardiolipin syndrome is reported with this code. Coders should note the Excludes1 note that appears in the code book for this code. D68.62: Lupus anticoagulant syndrome is reported by using this code. Lupus is a disease in which the body produces too many antibodies, which begin to turn against the patient's own body attacking body organs, joints, and muscles. D68.69: Other thrombophilia for which ICD-10-CM does not provide a specific code is assigned D68.69. D68.8: Other specified coagulation defects for which ICD-10-CM does not report a specific code are assigned D68.8. D68.9: Coagulation defect, unspecified, is coded with D69: Purpura and other hemorrhagic conditions are reported using this category of codes. Purpura is the accumulation of blood under the skin that forms multiple pinpoint hemorrhages. The following codes are used: D69.0: Allergic purpura. An extensive listing of diseases that are coded using this code appears in the code book, as well as an Excludes1 note that governs this code. D69.1: Qualitative platelet defects. An extensive listing of diseases that are coded using this code appears in the code book, as well as an Excludes1 note that governs this code. D69.2: Other nonthrombocytopenic purpura including purpura, purpura simplex, and senile purpura are reported with this code. D69.3: Immune thrombocytopenic purpura is reported by using this code. Thrombocytopenia is an abnormal decrease in platelet count that causes purpural hemorrhages. D69.4: Other primary thrombocytopenia is reported with this subcategory as follows: D69.41: Evans syndrome D69.42: Congenital and hereditary thrombocytopenia purpura. A notation appears in the code book that instructs the coder to "Code first congenital or hereditary disorder, such as: thrombocytopenia with absent radius (TAR syndrome) (Q87.2)". D69.49: This code reports other primary thrombocytopenia, including megakaryocytic hypoplasia and primary thrombocytopenia. D69.51 and D69.59: Secondary thrombocytopenia is reported using these codes. D69.51 reports posttransfusion purpure, while D69.59 reports other secondary thrombocytopenia. D69.6: Thrombocytopenia, unspecified, is reported with this code. If the documentation does not specify the type of thrombocytopenia, this code is used for thrombocytopenia, unspecified. D69.8: Other specified hemorrhagic conditions that include capillary fragility and vascular pseudohemophilia are reported with this code. D69.9: An unspecified hemorrhagic condition is reported with this code.

Other Disorders of the Blood and Blood-Forming Organs (Category Codes D70-D77)

D70: Category D70 reports neutropenia, which is further defined in ICD-10-CM as follows: D70.0: Congenital agranulocytosis, congenital neutropenia, infantile genetic agranulocytosis, and Kostmann's disease are reported with this code. D70.1: When assigning a code for agranulocytosis secondary to cancer chemotherapy, code D70.1, the coder is instructed to code any underlying neoplasms and to "Use an additional code for adverse affect, if applicable, to identify drug (T45.1X5)." D70.2: Other drug-induced agranulocytosis is reported using this code along with the appropriate T code (T36-T50 with fifth or sixth character 5) to identify the drug used. D70.3: Code D70.3 reports neutropenia due to infection. D70.4: Cyclic neutropenia, cyclic hematopoiesis, and periodic neutropenia are reported with this code. D70.8: Other neutropenia D70.9: Neutropenia, unspecified D71: Functional disorders of polymorphonuclear neutrophils are reported using this code. Polymorphonuclear neutrophils are white blood cells found in the peripheral blood and are the most numerous of the white blood cells. D72: Other disorders of white blood cells are reported with this category, which is differentiated as follows: D72.0: Genetic anomalies of leukocytes and other conditions listed in the extensive notation found in the code are reported with this code. D72.1: Code D72.1 reports eosinophilia, a condition in which the eosinophil white blood cell is found in excess in the blood or body tissues. This code is further divided. Reference the code manual for the complete listing of the codes such as code D72.110 which reports idiopathic hypereosinophilic syndrome and note the use of the fifth and sixth characters. D72.8: In this category, other specified disorders of white blood cells are differentiated more specifically in ICD-10-CM by use of the following codes: D72.81: This subcategory, Decreased white blood cell count, is further divided at the sixth character level to include: D72.810: Lymphocytopenia D72.818: Other decreased white blood cell count. The coder should read the listing of diseases that appear in the code book to become familiar with diseases that are reported via this code. D72.819: Decreased white blood cell count, unspecified D72.82: This category reports elevated white blood cell count, and it further specifies to the sixth character level as follows: D72.820> Lymphocytosis (symptomatic) and elevated lymphocytes D72.821: Monocytosis (symptomatic) D72.822: Plasmacytosis D72.823: Leukemoid reaction D72.824: Basophilia D72.825: Bandemia D72.828: Other elevated white blood cell count D72.829: Elevated white blood cell count, unspecified D72.89 and D72.9: D72.89 reports other specified disorders of white blood cells, while D72.9 reports a disorder of white blood cells, unspecified, as well as abnormal leukocyte differential. D73: Diseases of the spleen are coded to this category. The spleen is located in the upper left quadrant of the abdomen. The spleen forms lymphocytes and monocytes and also stores erythrocytes. This category is further divided using the following codes: D73.0: Hyposplenism D73.1: Hypersplenism D73.2: Chronic congestive splenomegaly D73.3: Abscess of spleen D73.4: Cyst of spleen D73.5: This code is used to report infarction of the spleen, nontraumatic splenic rupture, and torsion of the spleen. D73.8: Other diseases of the spleen are further differentiated as follows: D73.81: Neutropenic splenomegaly D73.89: Other diseases of spleen D73.9: Disease of the spleen, unspecified, is reported with this code. D74: Methemoglobinemia is a disorder of the hemoglobin in which oxygen is not transported by the cells. The codes are further divided: D74.0: Congenital methemoglobinemia D74.8: Other methemoglobinemias include the acquired methemoglobinemia conditions. D74.9: Methemoglobinemia, unspecified D75: Other and unspecified diseases of blood and blood-forming organs are reported with codes from the D75 category and are differentiated as follows: D75.0: This code for familial erythrocytosis includes benign and familial polycythemia. D75.1: Secondary polycythemia and other conditions that are listed in the extensive note for this code are reported with code D75.1. D75.8: Subcategory D75.8 reports other specified diseases of blood and blood-forming organs. This is further divided as follows: D75.81: Myelofibrosis. Numerous instructional notations appear in the code book for this code and must be followed for accurate code assignment. D75.82: Heparin-induced thrombocytopenia (HIT) D75.89: Other specified diseases of blood and blood-forming organs D75.9: Disease of blood and blood-forming organs, unspecified, is reported with this code. D75.A: Glucose-6-phosphate dehydrogenase (G6PD) deficiency without anemia. There is an EXCLUDES1 note for this code description that states that glucose-6-phosphate dehydrogenase (G6PD) deficiency with anemia is to be coded using code D55.0. D76: Certain diseases involving lymphoreticular and reticulohistocytic tissue are reported with the specific codes that follow. (The extensive Excludes1 note guides the coder in code selection.) D76.1: Hemophagocytic lymphohistiocytosis D76.2: This code is reported for hemophagocytic syndrome, infection-associated. The coder is instructed that an additional code is needed to identify the infectious agent or disease. D76.3: D76.3 reports other histiocytosis syndromes, including xanthogranuloma, reticulohistiocytoma, and sinus histiocytosis with massive lymphadenopathy. D77: Other disorders of the blood and blood-forming organs in diseases classified elsewhere are reported with this code.

Intraoperative and Postprocedural Complications of the Spleen (Category Code D78)

D78: This category reports intraoperative and postprocedural complications of the spleen, and the codes are differentiated as follows: D78.0: Intraoperative hemorrhage and hematoma of the spleen complicating a procedure are further divided and reported using the following codes: D78.01: Intraoperative hemorrhage and hematoma of the spleen complicating a procedure on the spleen D78.02: Intraoperative hemorrhage and hematoma of the spleen complicating other procedure D78.1: Accidental puncture and laceration of the spleen during a procedure is reported using: D78.11: Accidental puncture and laceration of the spleen during a procedure on the spleen D78.12: Accidental puncture and laceration of the spleen during other procedure D78.2: Postprocedural hemorrhage of the spleen following a procedure is reported with one of the following codes: D78.21: Postprocedural hemorrhage of the spleen following a procedure on the spleen D78.22: Postprocedural hemorrhage of the spleen following other procedure D78.31-D78.34: This range of codes reports postprocedural hematoma and seroma of the spleen following a procedure. D78.8: Other intraoperative and postprocedural complications of spleen are reported by using codes D78.81 or D78.89. It should be noted that these codes are governed by the instructional notation that states "Use additional code, if applicable, to further specify disorder." D78.81: Other intraoperative complications of the spleen D78.89: Other postprocedural complications of the spleen

Certain Disorders Involving the Immune Mechanism (Category Codes D80-D89)

D80: Immunodeficiency with predominantly antibody defects are reported using codes that are differentiated as follows: D80.0: Hereditary hypogammaglobulinemia, such as autosomal recessive agammaglobulinemia. Agammaglobulinemia is a hereditary disorder in which the immunoglobulin or immune proteins are extremely low, leaving the person open to frequent infections. D80.1: Nonfamilial hypogammaglobulinemia D80.2> Selective deficiency of immunoglobulin A [IgA] D80.3: Selective deficiency of immunoglobulin G [IgG] subclasses D80.4: Selective deficiency of immunoglobulin M [IgM] D80.5: Immunodeficiency with increased immunoglobulin M [IgM] D80.6: Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia D80.7: Transient hypogammaglobulinemia of infancy D80.8: Other immunodeficiencies with predominantly antibody defects D80.9: Immunodeficiency with predominantly antibody defects, unspecified D81: Combined immunodeficiencies are reported with the specific codes that follow. Coders should note the Excludes1 note at this level. D81.0: Severe combined immunodeficiency [SCID] with reticular dysgenesis D81.1: Severe combined immunodeficiency [SCID] with low T- and B-cell numbers D81.2: Severe combined immunodeficiency [SCID] with low or normal B-cell numbers D81.3: Adenosine deaminase [ADA] deficiency D81.30: Adenosine deaminase deficiency, unspecified D81.31: Severe combined immunodeficiency due to adenosine deaminase deficiency D81.32: Adenosine deaminase 2 deficiency. It should be noted that a "Code also" note appears for this code that instructs the coder to code associated manifestations. Review the code in the ICD-10-CM coding manual for more specific information. D81.39: Other adenosine deaminase deficiency. Review the ICD-10-CM coding manual for a listing of the various deficiencies types that are reported to this code. D81.4: Nezelof's syndrome D81.5: Purine nucleoside phosphorylase [PNP] deficiency D81.6: Major histocompatibility complex class I deficiency D81.7: Major histocompatibility complex class II deficiency D81.8: Other combined immunodeficiencies are coded with increased granularity as follows: D81.81: Biotin-dependent carboxylase deficiency disorders are specified as follows in ICD-10-CM. Providers may have to be queried to differentiate the deficiency so that a specific code can be assigned. D81.810: Biotinidase deficiency D81.818: Other biotin-dependent carboxylase deficiency D81.819: Biotin-dependent carboxylase deficiency, unspecified D81.89: Other combined immunodeficiencies not given a specific code in ICD-10-CM are reported with this code. D81.9: Combined immunodeficiency, unspecified, including severe combined immunodeficiency disorder, is reported with this code. D82: Immunodeficiency associated with other major defects is reported with codes from this category as follows: D82.0: Wiskott-Aldrich syndrome D82.1: Di George's syndrome D82.2: Immunodeficiency with short-limbed stature D82.3: Immunodeficiency following hereditary defective response to Epstein-Barr virus D82.4: Hyperimmunoglobulin E [IgE] syndrome D82.8: Immunodeficiency associated with other specified major defects D82.9: Immunodeficiency associated with major defect, unspecified D83: This category is used to report common variable immunodeficiencies. Documentation is essential when selecting codes because the codes are very specific as to the cell abnormalities. The diseases are reported as follows: D83.0: Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function D83.1: Common variable immunodeficiency with predominant immunoregulatory T-cell disorders D83.2: Common variable immunodeficiency with autoantibodies to B- or T-cells D83.8: Other common variable immunodeficiencies D83.9: Common variable immunodeficiency, unspecified D84: Other immunodeficiencies are coded using this category, which is differentiated as follows: D84.0: Lymphocyte function antigen-1 [LFA-1] defect D84.1: Defects in the complement system D84.8: Other specified immunodeficiencies are reported with codes at this level that are at times denoted to the the fifth and sixth character level. Review the coding manual for the specific characters. D84.9: Immunodeficiency, unspecified D86: Category D86 is used to report various forms of sarcoidosis. The following codes identify the sites of the sarcoidosis: D86.0: Sarcoidosis of lung D86.1: Sarcoidosis of lymph nodes D86.2: Sarcoidosis of lung with sarcoidosis of lymph nodes D86.3: Sarcoidosis of skin D86.8: Sarcoidosis of other sites are further differentiated within ICD-10-CM as follows: D86.81: Sarcoid meningitis D86.82: Multiple cranial nerve palsies in sarcoidosis D86.83: Sarcoid iridocyclitis D86.84: Sarcoid pyelonephritis D86.85: Sarcoid myocarditis D86.86: Sarcoid arthropathy D86.87: Sarcoid myositis D86.89: Sarcoidosis of other sites D86.9: Sarcoidosis, unspecified, is reported with this code. Prior to the assignment of this code, the provider should be queried to determine whether more specific information is available. D89: Other disorders involving the immune mechanism, not elsewhere classified, is reported and governed by the Excludes1 and Excludes2 notations that appear after the category heading in the code book. The codes are divided as follows: D89.0: Polyclonal hypergammaglobulinemia D89.1: Cryoglobulinemia is reported with this code, as well as the other diseases listed in the extensive notation that follows this code. D89.2: This code reports Hypergammaglobulinemia, unspecified. D89.3: This code reports Immune Reconstitution Syndrome. D89.4: This subcategory reports mast cell activation syndrome and related disorders using various fifth character levels for specificity. D89.8: Other specified disorders involving the immune mechanism, not elsewhere classified, are specified at the fifth and sixth character level in ICD-10-CM. The "Code first" and "Use additional" notations also govern code assignment. D89.9: Disorders involving the immune mechanism, unspecified code D89.9, reports unspecified disorders involving the immune mechanism and immune disease.

What disorders appear under code U07.0?

Dabbing related lung damage Dabbing related lung injury E-cigarette, or vaping, product use associated lung injury [EVALI] Electronic cigarette related lung damage Electronic cigarette related lung injury

Dehydration

Dehydration, the excess loss of fluids, is also a complication that can occur due to vomiting and diarrhea caused by the malignancy, chemotherapy, or radiation therapy. When a patient has experienced dehydration, an encounter or admission may be necessary to rehydrate the patient.

Arthropod-borne viral fevers and viral hemorrhagic fevers include: ** Reference category range A90-A99 for the complete list of fevers and viral diseases.

Dengue fever Mosquito-borne viral fever West Nile virus infection Rift Valley fever Zika virus Yellow fever

MODULE EIGHT CC & MCC

FLASHCARDS

Intellectual disabilities are genetic or acquired conditions in which there is decreased intelligence. The genetic causes of intellectual disabilities are: Acquired Causes, Signs & Symptoms, Testing, & Treatment

Down's syndrome, Hypothyroidism, and Phenylketonuria Acquired causes include: Birth injuries, Anoxia, Head trauma, Poor nutrition Premature birth, Prenatal maternal rubella or syphilis, Blood type incompatibility Signs and Symptoms: Children with intellectual disabilities show signs of decreased mental functioning compared to other children of the same age. Clinical Testing: IQ testing and observation of a child's functional levels confirm the diagnosis. Treatment: Treatment of patients with intellectual disabilities varies depending on their functioning level. Persons with severe intellectual disabilities are institutionalized because they are unable to care for themselves without assistance. Persons with mild intellectual disabilities are able to live fairly normal lives and to find employment with little psychological and social assistance.

Coding of Endocrine, Nutritional, and Metabolic Diseases Chapter 4 of ICD-10-CM is organized into the following blocks:

E00-E07, Disorders of thyroid gland E08-E13, Diabetes mellitus E15-E16, Other disorders of glucose regulation and pancreatic internal secretion E20-E35, Disorders of other endocrine glands E36, Intraoperative complications of endocrine system E40-E46, Malnutrition E50-E64, Other nutritional deficiencies E65-E68, Overweight, obesity, and other hyperalimentation E70-E88, Metabolic disorders E89, Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified

Category E04 reports nontoxic goiters and is differentiated at the fourth character level as follows:

E04.0—Nontoxic diffuse goiter E04.1—Nontoxic single thyroid nodule E04.2—Nontoxic multinodular goiter E04.8—Other specified nontoxic goiter E04.9—Nontoxic goiter, unspecified

Other common conditions classified to this code block are different types of thyroiditis. This is classified to category E06, which is summarized as follows:

E06.0: Acute thyroiditis, abscess of the thyroid, pyogenic thyroiditis, and suppurative thyroiditis are assigned this code. An additional code is needed to identify the infectious agent that is present. E06.1: Subacute thyroiditis, which includes granulomatous thyroiditis, giant-cell thyroiditis, and viral thyroiditis, are coded with this code. E06.2: Code E06.2 reports chronic thyroiditis with transient thyrotoxicosis. An Excludes1 note appears in the code book that excludes autoimmune thyroiditis from this code. E06.3: Autoimmune thyroiditis, Hashimoto's thyroiditis, hashitoxicosis (transient), lymphadenoid goiter, lymphocytic thyroiditis, and struma lymphomatosa are classified in this code. E06.4: Drug-induced thyroiditis is classified with this code. The code book instructs coders to "Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)." E06.5: Other chronic forms of thyroiditis are coded here, including chronic fibrous thyroiditis, chronic thyroiditis NOS, ligneous thyroiditis, and Riedel thyroiditis. E06.9: The last code in this subcategory is used to code unspecified thyroiditis.

Disorders of Other Endocrine Glands (Category Codes E20-E35) (EXCLUDES1 notation after the E20 to E35 block heading in the Tabular List of ICD-10-CM.)

E20: Hypoparathyroidism—This includes idiopathic, pseudo hypothyroidism, and other forms. E21: Hyperparathyroidism and other disorders of the parathyroid gland—This category is divided into primary, secondary, and other types of hyperparathyroidism as well as disorders of the parathyroid. E22: Hyperfunction of the pituitary gland—This category includes acromegaly and pituitary gigantism as well as hyperprolactinemia. E23: Hypofunction and other disorders of the pituitary gland—Hypopituitarism, diabetes insipidus, and other hypothalamic dysfunction are classified to this code. "Includes the listed conditions whether the disorder is in the pituitary or the hypothalamus." E24: Cushing's syndrome—Various forms of Cushing's syndrome are coded using category E24. E25: Adrenogenital disorders—This category includes both female and male adrenogenital disorders. Coders should be familiar with the extensive Includes note listed by the start of this category. E2: Hyperaldosteronism—The fourth digits differentiate primary, secondary, and other forms of hyperaldosteronism. E27: Other disorders of the adrenal gland—Some of the diseases classified here include adrenocortical overactivity, Addisonian crisis, drug-induced, and other adrenocortical insufficiencies, as well as adrenomedullary hyperfunction. E28: Ovarian dysfunction—Included in this category are codes for primary ovarian failure, polycystic ovarian syndrome, and other ovarian dysfunctions. E29: Testicular dysfunction—Hyperfunction and hypofunction testicular diseases are classified into this category. E30: Disorders of puberty, not elsewhere classified—Delayed, precocious, and other disorders of puberty are coded here. E31: Polyglandular dysfunction—This category codes diseases that involve dysfunction of multiple glands such as Schmidt's syndrome and multiple endocrine neoplasia syndromes. E32: Disease of the thymus—This category is differentiated by the fourth-digit level to indicate persistent hyperplasia of the thymus, abscess of the thymus, and other diseases of the thymus. E34: Other endocrine disorders—This category classifies other endocrine disorders and syndromes. E35: Disorders of endocrine glands in diseases classified elsewhere—Notations appear after the heading of this category to instruct the coder to "Code first underlying disease" and "Use additional code." Review the ICD-10-CM codebook and note the specific information related to these notations. E36: Intraoperative complications of the endocrine system—This category codes complications of the endocrine system, such as an intraoperative hematoma, that occurs during a procedure. The fourth and fifth digits identify the type of complication.

Malnutrition (Category Codes E40-E46) (EXCLUDES1 and EXCLUDES2 notes at the start of the E40 to E46 block heading in the Tabular)

E40, Kwashiorkor E41, Nutritional marasmus E42, Marasmic kwashiorkor E43, Unspecified severe protein-calorie malnutrition E44, Protein-calorie malnutrition of moderate and mild degree E45, Retarded development following protein-calorie malnutrition E46, Unspecified protein-calorie malnutrition

Other Nutritional Deficiencies (Category Codes E50-E64) and Overweight, Obesity, and Other Hyperalimentation (Category Codes E65-E68)

E50-E64: classifies nutritional deficiencies to codes, differentiating by type. E65-E68 are used to classify overweight, obesity, and other hyperalimentation. **E66 differentiates the type of obesity as obesity due to excess calories, drug-induced obesity, morbid obesity, and other and unspecified obesity. Following the category heading for E66, the following instructional notations appear: "Code first obesity complicating pregnancy, childbirth and the puerperium, if applicable (O99.21-)" and "Use additional code to identify body mass index (BMI), if known (Z68.-)." Coders should also be guided by the Excludes1 note that appears for this category.

Metabolic Disorders and Postprocedural Complications (Category Codes E70-E89)

E70-E89 blocks of codes include disorders of metabolism and postprocedural endocrine and metabolic complications and disorders. The coder should review the numerous notations that are found throughout this section including the EXCLUDES1 notation that appears after the E70 to E88 block heading in the Tabular List of ICD-10-CM. It should also be noted that many of the codes in the E70 to E88 range contain much detail in the code descriptions. E73 lactose intolerance codes are described as to the type of intolerance. If a patient has congenital lactase deficiency code E73.0 is assigned. If a patient has secondary lactase deficiency code E73.1 is assigned.

Infectious mononucleosis Clinical Testing:

Elevated WBC and atypical lymphocytes A positive monospot test Abnormal liver function tests

When is Follow-up Z code category Z08 used?

Encounter for follow-up examination after completed treatment for malignant neoplasm, is used when a patient is seen for follow-up after undergoing surgery, chemotherapy, radiation, or other treatment and when no evidence of a recurrence or metastasis exists. The follow-up Z codes are used to explain the continuing monitoring of the patient. This code implies that the neoplastic condition has been fully treated and no longer exists.

Infectious mononucleosis Signs and Symptoms:

Enlarged lymph nodes Fever Sore throat Malaise and fatigue Anorexia Myalgia Splenomegaly and mild hepatomegaly

Von Willebrand's disease, also known as angiohemophilia Signs and Symptoms:

Epistaxis Gingival bleeding Monorrhagia Gastrointestinal bleeding

When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g., tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify:

Exposure to environmental tobacco smoke (Z77.22) exposure to tobacco smoke in the perinatal period (P96.81) history of tobacco dependence (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0)

Coding of Mental, Behavioral, and Neurodevelopmental Disorders

F01-F09, Mental disorders due to known physiological conditions; includes mental disorders that have an etiology in cerebral disease, brain injury, or other cause that has led to cerebral dysfunction F10-F19, Mental and behavioral disorders due to psychoactive substance use F20-F29, Schizophrenia, schizotypal and delusional, and other non-mood psychotic disorders F30-F39, Mood [affective] disorders F40-F48, Anxiety, dissociative, stress-related, somatoform, and other nonpsychotic mental disorders F50-F59, Behavioral syndromes associated with physiological disturbances and physical factors F60-F69, Disorders of adult personality and behavior F70-F79, Intellectual disabilities F80-F89, Pervasive and specific developmental disorders F90-F98, Behavioral and emotional disorders with onset usually occurring in childhood and adolescence F99, Unspecified mental disorder

Mood [Affective] Disorders (Category Codes F30-F39)

F30, Manic episode—The fourth and fifth characters are used to identify the presence or absence of psychotic symptoms and the severity of the symptoms if they are present. F31, Bipolar disorder—Numerous fourth and fifth characters are used to classify the various forms of bipolar disorder. The coder needs to identify whether the patient is having a current episode of bipolar disorder or is in partial remission, and the level of severity. F32, Major depressive disorder, single episode—The coder should note the numerous diagnoses listed as an Includes note for this category. The coder also needs to read the patient's record to determine whether the disorder is a single or recurrent episode and the severity of the episode. Providers may have to be queried to determine the level of detail needed for code selection. F33, Major depressive disorder, recurrent—The coder should consult the Includes note that appears under the F33 category heading. The severity of the depressive disorder also needs to be determined for code selection: mild, moderate, severe, and associated psychotic symptoms. F34, Persistent mood [affective] disorders—This category includes cyclothymic disorders such as affective personality disorder, cycloid personality, cyclothymia, and cyclothymic personality, which are classified to F34.0. Dysthymic disorders are classified to F34.1 and include depressive neurosis, depressive personality disorder dysthymia, neurotic depression, and persistent anxiety depression. F34.8 classifies other persistent mood [affective] disorders, and F34.9 classifies persistent mood [affective] disorder, unspecified. F39, Unspecified mood [affective] disorder—This code includes affective psychosis.

Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonpsychotic Mental Disorders (Category Codes F40-F48)

F40, Phobic anxiety disorder—Common phobias classified here include agoraphobia, social phobias, and isolated phobias such as claustrophobia, acrophobia, fear of flying, and the like. Fourth, fifth, and sixth characters provide additional information. F41, Other anxiety disorder—Panic disorder, generalized and other mixed anxiety disorders are classified at the fourth-character levels in this category. F41.9, Anxiety, is a commonly used code in this category. F42, Obsessive-compulsive disorder—Obsessive-compulsive disorder is a psychoneurotic disorder. The patient has obsessions or compulsions and suffers extreme anxiety or depression that can interfere with the patient's ability to function occupationally, interpersonally, or socially. F43, Reaction to severe stress, and adjustment disorders—This category includes codes for combat fatigue, grief reaction, post-traumatic stress disorder, and other reactions to stress. Fourth characters are used to provide specificity to the codes. F44, Dissociative and conversion disorders—Dissociative disorders are characterized by emotional conflicts; the patient represses his or her emotions in such a manner that a separation in the personality occurs. The result can be a confusion in identity or an altered state of consciousness. Conversion disorders occur when a patient represses emotional conflicts, and sensory, motor, or visceral symptoms occur. The symptoms can include involuntary muscle movements, blindness, paralysis, aphonia, hallucinations, and choking sensations, to name a few. ICD-10-CM uses the fourth- and fifth-character levels to identify the disorder and the symptoms that occur. F45, Somatoform disorders—Somatoform disorders are characterized by symptoms that suggest a physical illness or disease but for which there is no organic cause or physiologic dysfunction. Fourth and fifth characters identify the specific somatoform disorder. F48, Other nonpsychotic mental disorders—The last category in this block of codes includes codes for neurosis, Dhat syndrome, neurasthenia, occupational neurosis, psychasthenia, and other nonpsychotic mental disorders. Fourth characters and instructional notations need to be referenced for this category.

Behavioral Syndromes Associated with Physiological Disturbances and Physical Factors (Category Codes F50-F59)

F50, Eating disorders—Anorexia nervosa and bulimia nervosa are classified here. Fourth and fifth characters provide additional detail for this category. F51, Sleep disorders not due to substance or known physiological condition. Coders need to reference the notations that appear at the various character levels within this category. F52, Sexual dysfunction not due to a substance or known physiological condition. Fourth and fifth characters provide additional code detail. F53, Mental and behavioral disorders associated with the puerperium, not elsewhere classified-This category is further divided to F53.0, Postpartum depression, and F53.1 Puerperal psychosis. Reference the ICD-10-CM coding manual and note the EXCLUDES1 note that governs this category. F54, Psychological and behavioral factors associated with disorders or diseases classified elsewhere—An instructional notation instructs the coder to "Code first the associated physical disorder, such as . . ."; therefore, two codes are needed. Please see the code book for the specific notation. F55, Abuse of nonpsychoactive substances—This category classifies, at the fourth character level, the abuse of substances such as antacids, herbal or folk remedies, laxatives, steroids, hormones, vitamins, and other substances. F59, Unspecified behavioral syndromes associated with physiological disturbances and physical factors—This includes psychogenic physiological dysfunction.

Disorders of Adult Personality and Behavior (Category Codes F60-F69)

F60, Specific personality disorders—Paranoid personality disorder, schizoid personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality disorder, obsessive-compulsive personality disorder, avoidant personality disorder, dependent personality disorder, and other personality disorders are differentiated at the fourth or fifth character levels within this category. F63, Impulse disorder—Impulse disorders are characterized by a sudden desire or urge to act without consideration of consequences that may result. Fourth and/or fifth characters identify pathological gambling, pyromania (fire setting), kleptomania (pathological stealing), trichotillomania (hair plucking), and other impulse disorders. F64, Gender identity disorders—This includes dual role transvestism and transsexualism. Coders need to read the instructional notations for this category for proper code assignment. F65, Paraphilias—Paraphilias are sexual perversions or deviations. Fourth characters are used to differentiate the types of paraphilias. F66, Other sexual disorders—These are classified to category F66 and include sexual maturation disorder and sexual relationship disorder. F68, Other disorders of adult personality and behavior—Codes F68.10 to F68.13 classify factitious disorders, which are characterized by disease symptoms that have been caused by the patient's deliberate actions to gain attention. F69, Unspecified disorder of adult personality and behavior—This category is used for disorders that are not specified by the provider as to the specific disorder.

MODULE FIVE Chapter 17: Diseases of the Skin and Subcutaneous Tissue Chapter 18: Diseases of the Musculoskeletal System and Connective Tissue Chapter 19: Diseases of the Genitourinary System

FLASH CARDS

MODULE FOUR: Chapter 14: Diseases of the Circulatory System Chapter 15: Diseases of the Respiratory System Chapter 16: Diseases of the Digestive System

FLASH CARDS

MODULE SEVEN Chapter 24: Injury, Poisoning, and Certain Other Consequences of External Causes Chapter 25: External Causes of Morbidity Chapter 26: Factors Influencing Health Status with Contact with Health Services

FLASH CARDS

MODULE THREE: Chapter 09: Endocrine, Nutritional, and Metabolic Diseases; Chapter 10: Mental, Behavioral, and Neurodevelopmental Disorders; Chapter 11: Diseases of the Nervous System; Chapter 12: Disorders of the Eye and Adnexa; Chapter 13: Diseases of the Ear and Mastoid Process

Flash cards

Introduction to the Body System Structures of the Endocrine System

Hypothalamus Pituitary gland Thyroid gland Adrenal glands Pancreatic islets Testicles (male) or Ovaries (female) Thymus gland Parathyroid glands Pineal gland

Inpatient vs Outpatient coding for suspected, rule-out, and possible diagnoses.

Inpatient: CAN be coded Outpatient: CANNOT be coded

Von Willebrand's disease, also known as angiohemophilia Clinical Testing:

Laboratory tests show prolonged bleeding time and a decrease in the vW factor level in plasma.

MCC

Major complication or comorbidity diagnosis that may affect DRG assignment

The numerous causes of osteoporosis include:

Malnutrition Decreased calcium absorption Inadequate calcium intake Estrogen deficiency As a side effect of some chronic diseases

Other Bacterial Diseases (Category Codes A30-A49) Diseases include:

Meningococcal meningitis Whooping cough Diphtheria ** Septic infections are also coded to this category; however, current medical practice makes a distinction between these terms and related conditions.

Mental and Behavioral Disorders Due to Psychoactive Substance Use (Category Codes F10-F19)

Mental disorders related to the excessive use of substances are classified to the F10-F19 codes. The codes in this block identify the drug of choice and the level of abuse or dependence.

Intellectual Disabilities (Category Codes F70-F79)

Mild intellectual disabilities—Code F70, an IQ of 50-55 to approximately 70, also referred to as mild mental subnormality or mild mental retardation Moderate intellectual disabilities—Code F71, an IQ of 35-40 to 50-55, also referred to as moderate mental subnormality or moderate mental retardation Severe intellectual disabilities—Code F72, an IQ of 20-25 to 35-40, also referred to as severe mental subnormality or severe mental retardation Profound intellectual disabilities—Code F73, an IQ below 20-25, also referred to as profound mental subnormality or profound mental retardation Other intellectual disabilities—Code F78 Unspecified intellectual disabilities—Code F79, used when the medical documentation states that the patient has intellectual disabilities but the level of functioning is not recorded; includes mental deficiency and mental subnormality

The CDC is also reviewing data that suggest that there may be other risk factors that include:

Moderate to severe asthma Type 1 Diabetes Cerebrovascular diseases Cystic fibrosis Hypertension Liver disease Pregnancy Smoking Thalassemia Pulmonary disorders—such as damage or scarred lung tissue Immunocompromised state caused by blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids and other immune weakening medicines

The detail of the codes requires that the coder identify the site that the condition is impacting. For example, for mumps the code book is differentiated as follows:

Mumps orchitis, B26.0 Mumps meningitis, B26.1 Mumps encephalitis, B26.2 Mumps pancreatitis, B26.3 Mumps with other complications, B26.81 to B26.89 Mumps without complications, B26.9

Acute Kidney Failure and Chronic Kidney Disease (Category Codes N17-N19) Category N18 contains instructional notations that appear in the Tabular List as follows:

N18 Chronic kidney disease (CKD) Code first any associated: diabetic chronic kidney disease (E08.22, E09.22, E10.22, E11.22, E13.22) hypertensive chronic kidney disease (I12.-, I13.-) Use additional code to identify kidney transplant status, if applicable (Z94.0)

Infectious intestinal diseases can be caused by a number of organisms. Signs and Symptoms:

Nausea Vomiting Anorexia Abdominal pain Fever Muscular aches Malaise

Viral hepatitis Signs and Symptoms:

Nausea Vomiting Fever Anorexia Malaise Enlarged and tender liver Jaundice Abdominal and gastric pain and discomfort Discolored stools, clay-colored Discolored urine, tea-colored

Other Diseases Caused by Chlamydiae (Category Codes A70-A74) Does NOT include, per Excludes1 note:

Neonatal chlamydial conjunctivitis Neonatal chlamydial pneumonia Reiter's disease Sexually transmitted chlamydial diseases

Is an acute exacerbation is equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection?

No. An acute exacerbation is a worsening or a decompensation of a chronic condition. An infection superimposed on a chronic condition is a frequent complication of drug therapy for microbial infection

Other Disorders of Glucose Regulation and Pancreatic Internal Secretion (Category Codes E15-E16)

Nondiabetic hypoglycemic coma (E15)—This includes drug induced insulin coma in nondiabetics, hyperinsulinism with hypoglycemic coma, and hypoglycemic coma NOS. Other disorders of pancreatic internal secretion (E16)—Fourth digits differentiate the codes as follows: E16.0—Drug-induced hypoglycemia without coma. Coders are directed by the following instructional notation: "Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)." Coders should also be directed by the following: Excludes1: diabetes with hypoglycemia without coma (E09.649), that appears after the code description. E16.1—Other hypoglycemia. An Excludes1 note appears for this code that excludes diabetes with hypoglycemia (E08.649, E10.649, E11.649, E13.649), hypoglycemia in an infant of a diabetic mother, and neonatal hypoglycemia from being reported with this code. E16.2—Hypoglycemia, unspecified. Note the Excludes1 notation that appears in the coding manual. E16.3—Increased secretion of glucagon E16.4—Increased secretion of gastrin E16.8—Other specified disorders of pancreatic internal secretion E16.9—Disorder of pancreatic internal secretion, unspecified

Complications Associated with Neoplasms

Numerous complications are associated with malignant neoplasms and their treatment. Patients commonly seek health care that is directed at the treatment of the complications, not at the treatment of the neoplasm.

Pregnant patients with neoplasm coding:

O9A.1 (followed by trimester code), first; neoplasm, second

Pernicious anemia Clinical Testing:

Pernicious anemia is confirmed by a positive Schilling test. Additional laboratory testing would show: Increased MCV Increased serum LDH Increased bilirubin Decreased WBC and platelet count Decrease in vitamin B12 serum Abnormal bone marrow

Hypothyroidism Causes, Signs & Symptoms, Clinical Testing, & Treatment

Possible causes: Surgery, Inflammatory conditions, Irradiation therapy, or Chronic autoimmune thyroid diseases Signs and Symptoms: In the early stages of hypothyroidism, the patient presents with: Fatigue, Weakness, Muscle cramps, Constipation, Arthralgias, Headache, or Thinning of nails and hair. In the later stages the patient may have: Slow speech, Thickening of the tongue, Puffiness of the face and eyelids, Decreased sense of smell and taste, Dyspnea, Pitting edema, Hypoventilation, Hypoxia, Hypothermia, Hyponatremia, or Hypotension Clinical Testing: The following results of lab testing indicate hypothyroidism: An increase in serum cholesterol and prolactin, Elevated liver enzymes and creatine An increase in TSH, or Low-to-normal serum T4 levels Treatment: Patients are treated with medication, the most common of which is Levothyroxine.

Primary and Secondary Malignancies coding

Primary Malignancy Only: When the primary malignancy is the only condition treated, designate the primary malignancy as the principal diagnosis. Secondary Malignancy Only: When treatment is directed only at the secondary, or metastatic malignancy, the secondary site is designated as the principal diagnosis, unless the admission is for chemotherapy, immunotherapy or radiotherapy. An additional code is assigned for the primary site. Primary and Secondary Malignancy: When the treatment is directed equally at both primary and secondary malignancies, the primary malignancy is sequenced as the principal diagnosis and the secondary malignancy is sequenced as an additional code

Name of Infection & Common Pathogen

Pseudomembraneous colitis: Clostridium difficile Salmonella food poisoning: Salmonella Urinary tract infection: E. coli & Pseudomonas aeruginosa Tuberculosis: Mycobacterium tuberculosis Impetigo: Streptococci A Strep throat: Streptococcus

Complications of care

Requires a cause-effect relationship between care provided and the condition; and the condition documentation that is is a complication.

Multiple Sclerosis (MS) Signs & Symptoms, Clinical Testing, & Treatment

Signs and Symptoms: The symptoms of MS vary from person to person and include: Numbness in the limbs, Visual disturbances, Muscle weakness, Emotional problems, such as mood swings and depression, & Urinary problems, such as incontinence, urgency, or frequency Clinical Testing: MS is difficult to diagnose. Testing may include: Electrophoresis, Computed tomography (CT) and magnetic resonance imaging (MRI) scans, Lumbar puncture, & Electroencephalography (EEG) Treatment: Patients with MS receive symptomatic treatment, such as physical therapy and steroid treatment, to relieve the symptoms.

Hyperthyroidism Signs & Symptoms, Clinical Testing, & Treatment

Signs and Symptoms: Enlarged thyroid gland, Accelerated metabolic processes of the body, Tachycardia, Nervousness, Excessive excitability, Increased appetite with weight loss, Tremors, Fatigue, Heat intolerance, Diarrhea, Moist skin, or extreme thirst Clinical Testing: Serum T3, T4, thyroid resin uptake, and free thyroxine index are elevated; TSI levels are usually high; Serum ANA and anti-double-stranded DNA antibodies are usually elevated; Thyroid radioactive iodine uptake and scan are often performed; or MRI, CT scanning, and ultrasound are performed to visualize ophthalmopathy. Treatment: Depending on the intensity of the hyperthyroidism, the following treatment options are considered: Medications, such as propylthiouracil or methimazole, Radioactive iodine to destroy the over-functioning of the thyroid tissue, Thyroid surgery to remove part or all of the thyroid gland (When removal of the entire thyroid gland occurs, hormonal supplements are needed for the rest of the patient's life), Radiation of the thyroid

Pernicious anemia Treatment:

Since intrinsic factor is not being produced, the patient's body inadequately absorbs vitamin B12. Therefore, the patient receives monthly injections of vitamin B12 for his or her lifetime.

Arrangements of bacteria are Single, Pairs, Chains, & Clusters. What is the medical word part for each?

Single = There is no specific medical term. Pairs = diplo- Chains = strepto- Clusters = staphylo-

Singular Name of Bacterial Shape Plural Form Description

Singular: Coccus, Bacillus, Spirillum Plural: Cocci, Bacilli, Spirilla Description: Coccus: Spherical or round Bacillus: Straight rod Spirillum: Spiral, corkscrew, or slightly curved

Other Spirochetal Diseases (Category Codes A65-A69) Meaning/DEfinition:

Spirochetal is a term for a gram-negative bacteria made up of spiral-shaped cells. This code block contains codes for nonvenereal syphilis, yaws, pinta, relapsing fevers, and other spirochetal infections, as well as Lyme disease. The Excludes2 note at the beginning of the code set excludes leptospirosis and syphilis, which are located in other areas of the chapter.

COPD (Chronic obstructive pulmonary disease) 4 stages:

Stage I: Mild COPD. Stage II: Moderate COPD. Stage III: Severe COPD. Stage IV: Very severe COPD.

Medical Necessity

Supporting reason for why a service was done. What prompted the provider to perform the service.

aporosity

Swiss-cheese appearance of the bones, creating a decrease in bone mass.

An underdose or overdose of insulin due to an insulin pump failure should be assigned to a code from subcategory:

T85.6

Infections with a Predominantly Sexual Mode of Transmission (Category Codes A50-A64)

The Excludes1 notation at the start of this subcategory acts as a guide to coding for human immunodeficiency virus (HIV) disease, Reiter's disease, and nonspecific and nongonococcal urethritis. These conditions are found in other categories of the code book.

Other Disorders of Ear (Category Codes H90-H94) and Intraoperative and Postprocedural Complications and Disorders of Ear and Mastoid Process, Not Elsewhere Classified (H95)

The last block of codes in this chapter of ICD-10-CM consists of the following categories, with the use of fourth, fifth, and/or sixth characters: H90, Conductive and sensorineural hearing loss—This category is differentiated to identify the type of hearing loss and whether the hearing loss is unilateral or bilateral. The types of hearing loss include conductive, sensorineural, and mixed. H91, Other and unspecified hearing loss—This category is used to report other and unspecified hearing loss, including ototoxic, presbycusis, sudden idiopathic, and other specified and unspecified forms of hearing loss. H92, Otalgia and effusion of ear—A number of common disorders are coded to this category: Otalgia—Earache Otorrhea—Discharge from the external ear Otorrhagia—Hemorrhage from the ear H93, Other disorders of ear, not elsewhere classified—Degenerative and vascular disorders of the ear, tinnitus, other abnormal auditory perceptions, disorders of the acoustic nerve, and other specified disorders of the ear are categorized here. H94, Other disorders of ear in diseases classified elsewhere—Coders are instructed to "Code first underlying disease, such as parasitic disease (B65-B89)" for this category. Reference the headings of H94.0 and H94.8 to review the instructional notations. H95, Intraoperative and postprocedural complications and disorders of ear and mastoid process, not elsewhere classified—This category is used to report complications in the ear and mastoid process that occurred during a procedure or postprocedure.

Diseases of Inner Ear (Category Codes H80-H83)

This block of codes, with the use of fourth, fifth, and/or sixth characters, is used to report diseases of the inner ear. The categories that are present include: H80, Otosclerosis—Otosclerosis is the growth of spongy bone in the inner ear. The growth can progress, causing the obstruction of the oval or round window and progressive deafness. This category is differentiated according to the site of the otosclerosis and the ear involved. H81, Disorders of vestibular function—Included in this category of codes is Ménière's disease, benign paroxysmal vertigo, vestibular neuronitis, other peripheral vertigo, and other vestibular disorders. H82, Vertiginous syndromes in diseases classified elsewhere—An instructional notation directs the coder to "Code first underlying disease." H83, Other diseases of inner ear—This category is used to code labyrinthitis, labyrinthine fistula, labyrinthine dysfunction, noise effects on the inner ear, and other diseases.

Diseases of the External Ear (Category Codes H60-H62)

This category is differentiated according to the various types of otitis, with fourth, fifth, and sixth characters providing additional detail about the condition: Abscess of external ear Cellulitis of external ear Malignant otitis externa Infective otitis externa Cholesteatoma of external ear Acute noninfective otitis externa

Pulmonary edema, category J81, contains an instructional notation that instructs the coder to use additional code to identify... and an Excludes1 note that states...

Use additional code to identify: exposure to environmental tobacco smoke (Z77.22) history of tobacco dependence (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0) Excludes1: chemical (acute) pulmonary edema (J68.1) hypostatic pneumonia (J18.2) passive pneumonia (J18.2) pulmonary edema due to external agents (J60-J70) pulmonary edema with heart disease NOS (I50.1) pulmonary edema with heart failure (I50.1)

Chapter 22 of ICD-10-CM gives specific guidelines for what disorder?

Vaping-Related Disorders

Blood Composition: Whole Volume & Leukocytes

WHOLE BLOOD: Plasma (55% of total volume); Formed (45%), Erythrocytes, Neutrophil, & Basophil LEUKOCYTES: Thrombocytes (platelets), Monocyte, & Lymphocyte

Treatment Followed by Recurrence

When a patient is treated for a malignancy, whether it is with chemotherapy, radiation, or surgery, and there is evidence that the cancer has recurred, the primary malignancy is the principal diagnosis.

Excised Malignancy Followed by Recurrence

When a previously excised malignancy recurs, the code for the malignancy is used for the principal diagnosis.

Sequencing of Codes

When coding for the treatment of neoplasms, a coder must read the patient's record to determine the reason for the visit or admission.

What External Causes of Morbidity codes are used once?

Y92 (place of encounter): assigned only at initial encounter Y93 (activity code): assigned only at initial encounter Y99 (status code): assigned ONLY when other codes are used at initial encounter.

Human Immunodeficiency Virus (HIV) Disease (Category Code B20) Official Coding Guidelines

a. Human Immunodeficiency Virus (HIV) Infections 1) Code only confirmed cases 2) Selection and sequencing of HIV codes (a) Patient admitted for HIV-related condition (b) Patient with HIV disease admitted for unrelated condition (c) Whether the patient is newly diagnosed Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision. (d) Asymptomatic human immunodeficiency virus Z21, (e) Patients with inconclusive HIV serology (f) Previously diagnosed HIV-related illness (g) HIV Infection in Pregnancy, Childbirth and the Puerperium (h) Encounters for testing for HIV

What of the following is an example of a violation of the ethical principles? a. upcoding b. researching a condition c. querying a provider d. consistent coding

a. upcoding

diverticlosis

abnormal condition of the pouches or sacs in the lining of the intestine known as diverticula.

Cerebrovascular disease

abnormal nontraumatic conditions that affect the cerebral arteries.

Viral Hepatitis (Category Codes B15-B19) CTo appropriately code hepatitis, the coder must first identify whether the hepatitis is:

acute or chronic, or unspecified, and the type of hepatitis

Teratogens

agents that cause defects in an embryo.

Moderate intellectual disabilities

an IQ of 35-40 to 50-55; also referred to as moderate mental subnormality or moderate mental retardation.

Mild intellectual disabilities

an IQ of 50-55 to approximately 70; also referred to as mild mental subnormality or mild mental retardation.

Hyperparathyroidism

an abnormal condition of the parathyroid glands in which there is an excessive secretion of parathyroid hormone.

Dowager's hump

an abnormal curvature in the upper thoracic spine.

Thrombocytopenia

an abnormal decrease in platelet count that causes purpural hemorrhages.

Neutropenia

an abnormal decrease of granular leukocytes in the blood.

Dysplasia

an abnormal development or growth of cells.

benign prostatic hypertrophy (BPH)

an abnormal enlargement of the prostate.

endometriosis

an abnormal growth of the endometrium outside the uterus.

pulpitis

an abscess of the pulp.

Unstable Angina (UA)

an accelerating, or crescendo, pattern of chest pain that occurs at rest or during mild exertion, typically lasting longer than angina pectoris and not responsive to medication.

hydrocephalus

an accumulation of fluid in the cranial meninges.

Infectious mononucleosis is:

an acute infection caused by the Epstein-Barr virus.

Tabular List of Diseases and Injuries (Tabular)

an alphanumerical list of codes commonly referred to as the Tabular; divided into chapters based on body system (anatomical site) or condition (etiology).

Sickle-cell trait

an asymptomatic condition in which the patient receives the genetic trait from only one parent.

rheumatoid arthritis

an autoimmune disease in which the synovial membranes are inflamed and thickened.

Pernicious anemia

an autoimmune disorder in which the stomach is unable to produce intrinsic factor needed to absorb vitamin B12.

ovarian cysts

an encapsulated sac of the ovary that is filled with semisolid or liquid material.

Developmental dyspraxia

an impaired ability to perform coordinated movements in the absence of any defect in sensory or motor functions.

Trichotillomania

an impulse disorder characterized by the desire to pluck hair.

Pyromania

an impulse disorder characterized by the desire to set fires.

Ischemic heart attack

an inadequate supply of blood to the heart caused by an occlusion.

hypertension

an increase in systolic pressure, diastolic pressure, or both.

Tuberculosis

an infection caused by Mycobacterium tuberculosis that spreads throughout the body via lymph and blood vessels and that most commonly localizes in the lungs.

periapical abscess

an infection of the pulp and surrounding tissue.

cystitis

an inflammation of the bladder.

Bursitis

an inflammation of the bursa.

Hemoglobin (Hgb)

contained in red blood cells that absorbs oxygen and transports it to the tissues of the body.

Integumentary

covering or outer layer.

In the outpatient setting, the term first-listed diagnosis is used in lieu of ________ diagnosis. a. primary b. first-referenced c. final d. principal

d. principal

If the face sheet, diagnostic testing reports, and the discharge summary contain different diagnoses, you should: a. use the diagnoses on the face sheet b. select all the diagnoses on all three forms of documentation c. use the diagnoses on the discharge summary d. query the provider for clarification

d. query the provider for clarification

vocal cords

ligaments that produce sound or speech when air passes through them.

Body Mass Index (BMI)

figured by taking a person's weight and height and figuring the index of fat in relation to these elements.

Pinna

flexible cartilaginous flap that has a bottom portion known as the ear lobe.

Aqueous humor

fluid that fills the two cavities of the interior of the eye.

urine

fluid waste

Laterality

for bilateral sites ICD-10-CM indicates the specific site.

Juvenile diabetes, IDDM

form of diabetes in which the patient has an insufficient amount of insulin secretions, requiring insulin injections; also known as type I diabetes mellitus.

ankylosing spondylitis

form of rheumatoid arthritis in which there is a chronic inflammation of the spine and sacroiliac joints that leads to the stiffening of the spine.

Cholelithiasis

formation or presence of gallstones.

bronchi

formed when the trachea branches off in the chest.

anterior

forward or front.

nephrons

found in the kidneys and used to filter, reabsorb, and secrete urine.

Semicircular ducts

found in the middle ear; aid in balance.

nonunion fracture

fracture fragments fail to unite.

postpartum

from birth until 6 weeks after the birth.

third-degree burns

full-thickness burn affecting the epidermis, dermis, and subcutaneous layers.

Canthus

inner edge of the eye.

Code Also

instructs the coder that two codes may be needed to fully code the diagnostic phrase being coded; no sequencing directions are provided.

Use Additional Code

instructs the coder to use an additional code to identify the manifestation that is present.

Folate deficient anemia

insufficient amounts of folic acid, which is needed for proper cell reproduction and growth.

Auricle

known as the pinna or earlobe.

Choroids

layer just beneath the sclera containing capillaries that provide the blood supply and nutrients to the eye.

Suspensory ligaments

ligaments that attach to the lens and hold it in place.

Noninfiltrating carcinoma

neoplastic cells that are undergoing malignant changes confined to the original epithelium site without invading surrounding tissues; also known as transitional cell carcinoma, carcinoma in situ, noninvasive carcinoma, and preinvasive carcinoma in situ.

Transitional cell carcinoma

neoplastic cells undergoing malignant changes and confined to the original epithelium site without invading surrounding tissues; also called carcinoma in situ, noninfiltrating carcinoma, noninvasive carcinoma, and preinvasive carcinoma.

Noninvasive carcinoma

neoplastic cells undergoing malignant changes that are confined to the original epithelium site without invading surrounding tissues; also called transitional cell carcinoma, noninfiltrating carcinoma, carcinoma in situ, and preinvasive carcinoma.

Preinvasive carcinoma

neoplastic cells undergoing malignant changes that are confined to the original epithelium site without invading surrounding tissues; also called transitional cell carcinoma, noninfiltrating carcinoma, noninvasive carcinoma, and carcinoma in situ.

Influenza and Pneumonia (Category Codes J09) EXCLUDES:

nfluenza A/H1N1 (J10.-) influenza due to other identified influenza virus (J10.-) influenza due to unidentified influenza virus (J11.-) seasonal influenza due to other identified influenza virus (J10.-) seasonal influenza due to unidentified influenza virus (J11.-)

Nonmalignant tumors

not life-threatening, benign

Includes

note used to define and/or give examples of the content of a particular category or a block of category codes.

Code First

notes appearing in the Tabular section of ICD-10-CM and identifying for the coder the sequence of the code assignment.

Excludes

notes used to signify that the conditions listed are not assigned to the category or block of category codes.

inanimate object

object that is not alive or able to move (animate) on its own power.

sign

observed by the physician/provider and objective evidence of disease.

aspiration pneumonia

occurs when a solid or liquid is inhaled into the lung.

Single-code assignment

occurs when only one code is needed to code the diagnostic statement.

Hemolytic anemia

occurs when red blood cells are broken down at a faster rate than bone marrow can produce them.

partial placenta previa

occurs when the placenta covers part of the cervical os.

Complete placenta previa

occurs when the placenta entirely covers the cervical os.

Platelets

ovoid-shaped structures that initiate blood clotting.

Covid-19 was declared by the World Health Organization in March 2020 and is also known as:

pandemic SARA-CoV-2

inginual hernia

part of the intestine passes through a weak point or tear in the abdominal wall.

subluxation

part of the joint surface has moved away from where it should be; also called a partial dislocation.

Kleptomania

pathological stealing.

DRG assignment (diagnosis-related group):

patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives.

hepatic

pertaining to the liver

comorbidity

presence of two or more diseases or medical conditions in a patient.

resuscitation

procedure performed to restore cardiac and/or respiratory function.

Coagulation

process of blood clotting

labor and delivery

process of childbirth.

Chronic Kidney Disease (CKD)

progressive disease in which renal failure increases, causing multisystem problems.

chronic renal failure

progressive disease in which renal failure increases, causing multisystem problems.

chronic bronchitis

prolonged inflammation lasting for more than 3 months and occurring for two consecutive years.

chronic sinusitis

prolonged inflammation of one or more of the sinus cavities.

White blood cells (WBC)

protect the body from disease; also called leukocytes.

tonsils

protect the entrance to the respiratory system.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Revision (DSM-5)Diagnostic and Statistical Manual of Mental Disorders, Fifth Revision (DSM-5)

psychiatric disorders diagnosed by psychiatrists most commonly are recorded using the nomenclature established by the American Psychiatric Association and set forth in the DSM-5.

Angina pectoris

severe chest pain caused by an insufficient amount of blood reaching the heart.

Myelophthisis

severe form of anemia in which certain bone marrow material shows up in the peripheral blood.

Grand mal

severe seizure.

Paraphilias

sexual perversions or deviations.

vertebral column

shields the spinal column and is made up of cervical, thoracic, and lumbar vertebra.

cutane

skin

Hypnotics

sleep-inducing agents.

Cartilage

smooth, nonvascular connective tissue that comprises the more flexible parts of the skeleton.

Cochlea

snail-shaped, bony structure in the ear that transmits sound.

CC exclusion:

some instances an MCC or CC designation for secondary diagnosis codes will be negated due to its relationship with the principal diagnosis.

Principal diagnosis

the condition defined after study as the main reason for admission of a patient to the hospital.

embryo

the developing child from conception through the eighth week of pregnancy.

fetus

the developing child from the ninth week until birth.

stroke

the disruption in the normal blood supply to the brain; also called a cerebrovascular accident.

Lacrimal duct

the duct that drains the tears from the eye through the eye and that is located at the inner edge of the eye.

cecum

the end of the ileum and the start of the large intestine.

female genitalia

the female reproductive organs.

missed abortion

the fetus has died before the completion of 22 weeks of gestation, with the retention of the dead fetus or products of conception for up to 4 weeks after demise.

Discharge disposition (inpatient):

the final place or setting to which the patient was discharges on the day of discharge.

Ear lobe

the flexible cartilaginous flap that has a bottom portion known as the pinna.

synovia

the fluid that acts as a lubricant for joints, tendon sheath, or bursa.

Morphology

the form and structure of neoplastic growth of cells.

malunion fracture

the fracture site is misaligned.

rheumatism

the general term for the deterioration and inflammation of connective tissue, including muscles, tendons, synovium, and bursa.

Lacrimal gland

the gland that produces tears.

Metastasize

the growing and spreading of cancer to other body parts.

thrombophlebitis

the inflammation of a vein with the formation of a thrombus.

phlebitis

the inflammation of a vein.

Otitis externa

the inflammation of the external auditory canal.

endocarditis

the inflammation of the inner layer of the heart.

nephritis

the inflammation of the kidneys.

Meningitis

the inflammation of the membranes, or meninges, of the spinal cord or brain.

Omphalitis

the inflammation of the navel.

pericarditis

the inflammation of the outer layers of the heart.

voiding

urination or micturating

hives

urticaria

Insulin

used by the body to process glucose.

Parentheses

used in both Tabular List and Alphabetic Index around terms providing additional information about the main diagnostic term.

See

used in the Alphabetic Index and instructs the coder to cross-reference the term or diagnosis following the notation.

Brackets

used in the Tabular Listing and Alphabetic Index to enclose synonyms, alternative wording, abbreviations, or explanatory phrases.

Colon

used in the Tabular listing after a term that is modified by one or more terms following the colon.

diagnostic examinations

used to confirm or rule out a suspected diagnosis due to signs and symptoms that the patient has experienced.

U codes

used to report encounters when the circumstances surrounding the encounter are for something other than disease or injury.

Z codes

used to report encounters when the circumstances surrounding the encounter are for something other than disease or injury.

NEC (not elsewhere classified)

used to signal coders that the term being coded is considered a general term.

Excludes2

used to signify that the diagnostic terms listed after the note are not part of the condition(s) represented by the code or code block.

Excludes1

used to signify that the diagnostic terms listed are not coded to the category or subcategory; therefore, the two conditions are mutually exclusive. ("Not Coded Here).

Acute rheumatic fever develops, ...

usually in children ages 5-15 years